Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ALL-136 November 2005 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: All Provider Manuals (Revised Appendix A) This letter transmits a revised Appendix A for all provider manuals. Appendix A is a directory of MassHealth-related addresses, phone numbers, fax numbers, and e-mail addresses. Appendix A is also available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on “Provider Library,” then on “Provider Manual Appendices.” If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages A-1 through A-16 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages A-1 through A-16 — transmitted by Transmittal Letter ALL-134 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-1 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 This appendix contains the names, addresses, and telephone numbers of units, agencies, and contractors that you may need to contact in the course of doing business with MassHealth. This appendix is also available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on “Provider Library,” then on “Provider Manual Appendices.” This directory is organized alphabetically by function. Contents Benefit Plans and Utilization Management 2 Claims Submission and Resolution 3 Final Deadline Appeals 5 Hearings 5 Member Eligibility 6 Payments 7 Prior Authorization (pharmacy services) 8 Prior Authorization (non-pharmacy services) 9 Provider Enrollment and Credentialing 10 Provider Training 11 Publications 12 Third-Party Liability 14 Vision Care Materials 15 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-2 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Benefit Plans and Utilization Management MassHealth has entered into agreements with various entities to manage and review the quality and appropriateness of care. If you have questions about the PCC Plan, PCC Plan Network Management Services, or referral requirements: PCC Plan Hotline 1-800-495-0086 (TTY: 617-790-4130 for people with partial or total hearing loss) 617-790-4138 (fax) If you have questions about service authorization or claims for members enrolled in the Behavioral Health Program: 1-800-495-0086 617-790-4185 (fax) If you have questions about the Acute Hospital Utilization Management Program, including: -admission screening; -prepayment review; -OPD PCC review; and -postpayment review MassPRO 235 Wyman Street Waltham, MA 02451-1231 781-890-0011 and 781-419-2700 For admission screening only: 1-800-732-7337 1-800-752-6334 (fax) For prepayment review only: 781-290-5784 (fax) If you have questions about the Chronic Disease and Rehabilitation Hospital Utilization Management Program, including: -admission screening -prepayment review -postpayment review For preadmission screening; conversion screening, and concurrent review: MassPRO 235 Wyman Street Waltham, MA 02451-1231 781-890-0011 and 781-419-2700 1-800-554-5127 1-800-752-6334 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-3 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Claims Submission and Resolution MassHealth has contracted with MAXIMUS to receive MassHealth claims, except for pharmacy claims, and to answer providers' questions about the payment of services covered by MassHealth. MassHealth Customer Services: If you have questions about claims or MassHealth policy, or want to request a replacement remittance advice: MassHealth ATTN: Customer Service P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 Hours: Mon. – Fri., excluding holidays 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net If you have a question about the status of a claim 1-800-841-2900 Hours: Mon. – Fri., excluding holidays 8:00 A.M. – 5:00 P.M. www.massrevs.eds.com If you have questions about policies and procedures for submitting electronic claims, technical support, or testing for HIPAA claims transactions: 1-800-841-2900 Hours: Mon. – Fri., excluding holidays hipaasupport@mahealth.net After you are approved to submit claims electronically, upload your HIPAA-compliant electronic claims to the Web-Based Transactions page at: www.mass.gov/masshealth If you have questions about Provider Claim Submission Software (PCSS): 1-800-841-2900 Hours: Mon. – Fri., excluding holidays 8:00 A.M. – 5:00 P.M. providersupport@masshealth.net Send original paper claims to: MassHealth ATTN: Originals P.O. Box 9118 Hingham, MA 02043 Send paper adjustments of all paid claims to: MassHealth ATTN: Adjustments P.O. Box 9118 Hingham, MA 02043 Send paper resubmittals of all denied claims to: MassHealth ATTN: Resubmittals P.O. Box 9118 Hingham, MA 02043 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-4 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Send voids of all claims paid in error to: MassHealth ATTN: Voids P.O. Box 9118 Hingham, MA 02043 If you have Medicare/MassHealth claims that do not cross over systematically, send paper crossover claims to: MassHealth ATTN: Crossover Claims P.O. Box 9118 Hingham, MA 02043 Send all 90-day waiver requests: (except pharmacy claims) MassHealth ATTN: 90-Day Waivers P.O. Box 9118 Hingham, MA 02043 For questions about final deadline appeals, contact the Final Deadline Appeals Unit at: MassHealth ATTN: Final Deadline Appeals 600 Washington Street Boston, MA 02111 617-210-5538 fdeappeals@state.ma.us MassHealth has contracted with ACS State Healthcare (ACS) to receive MassHealth pharmacy claims and answer providers’ questions about the Pharmacy Online Processing System (POPS). ACS Help Desk: 1-866-246-8503 24 hours a day, seven days a week If you have questions about 90-day waiver requests for pharmacy claims: Fax the completed form and any pertinent documentation to: ACS Help Desk 1-866-246-8503 1-866-556-9315 (fax) Send written questions related to claims, MassHealth policy, registration for electronic remittance advices, or replacement of a remittance advice to: ACS State Healthcare ATTN: MassHealth 260 Franklin St Suite 1020 Boston, MA 02110 masshealth.providerrelations@acs-inc.com Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-5 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Final Deadline Appeals If the service date on the claim exceeds 12 months (or 18 months, if another insurer is involved), and has received a final deadline exceeded edit (888), submit your appeal to: MassHealth ATTN: Final Deadline Appeals Unit 600 Washington Street Boston, MA 02111 617-210-5538 fdeappeals@ state.ma.us Hearings If you are an applicant, member and/or appeal representative and have questions about a fair hearing, or you are a provider with questions about an adjudicatory hearing, submit your questions to: Board of Hearings MassHealth 2 Boylston Street Boston, MA 02116 617-210-5800 1-800-655-0338 617-210-5820 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-6 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Member Eligibility MassHealth has contracted with Electronic Data Systems (EDS) to maintain and monitor the MassHealth Recipient Eligibility Verification System (REVS). This system provides 24-hour access to member eligibility information for the previous 12 months. Be sure to have the member’s card, MassHealth identification number, or name and date of birth when making eligibility inquiries. REVS access methods require a user ID and password. If you have not submitted a Trading Partner Agreement, you cannot access REVS. ACS, the contractor responsible for operating the Pharmacy Online Processing System (POPS), receives the same MassHealth member eligibility information as EDS. The pharmacy claim-adjudication process at ACS includes the same eligibility verification as is available through REVS. Therefore, it is not necessary for retail pharmacists to separately validate through REVS member eligibility for pharmacy claims. WebREVS Automated Voice Response (AVR): www.massrevs.eds.com 1-800-554-0042 Eligibility Operator (24-hour eligibility operator): 1-800-833-7582 REVS Help Desk: Answers questions about: -REVS access methods (WebREVS, point-of-service, PC software, and automated-voice-response systems) -MassHealth cards -REVS Provider Manual -availability of REVS -how to verify eligibility 1-800-462-7738 Hours: Mon.– Fri., excluding holidays 8:00 A.M. – 5:00 P.M. REVSHelpDesk@eds.com Send correspondence to: EDS MassHealth 155 Federal Street, 6th Floor Boston, MA 02110 617-350-8180 (fax) If members have questions about MassHealth, they should call the MassHealth Customer Service Center: 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-7 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Payments Providers are encouraged to receive MassHealth payments by electronic funds transfer (EFT). To receive payments by EFT, you must complete the Authorization for Electronic Funds Transfer (EFT) of MassHealth Payments. The authorization form is available for download from our Web site at www.mass.gov/masshealth (click on “Information For MassHealth Providers”, and then “MassHealth Provider Forms.”) Your EFT request will not be approved unless you have a W-9 form on file. The W-9 form can also be downloaded from the Web according to the above guidelines. Send the completed EFT form (and W-9 form, if applicable) to: If you have questions about W-9 or EFT form completion: MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) providersupport@mahealth.net For replacement of a lost or damaged check: 617-210-5072 MassHealth payment information is available online. You may access the amount of your check or EFT by going to the Office of the State Comptroller’s Web site at www.mass.gov/massfinance. Go to “VendorWeb” and follow the instructions. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-8 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Prior Authorization (pharmacy services) Claims for certain drugs submitted through the Pharmacy Online Processing System (POPS) require prior authorization (PA). Please see Subchapter 4 of your provider manual and the MassHealth Drug List on the MassHealth Web site at www.mass.gov/masshealth. Click on “MassHealth Drug List.” Other claims will be denied because of certain drug utilization review (DUR) edits. Where appropriate, the pharmacist should discuss the medical necessity of prescribing such drugs with the prescriber before calling for DUR certification. Use the following telephone and fax numbers to request DUR certification or to check on the status of your pharmacy PA request if you have not received a response within 24 hours. If you have not received a response within 24 hours, the pharmacist may provide a 72-hour supply of a requested covered drug. University of Massachusetts Medical Center: 1-800-745-7318 1-877-208-7428 (fax) Send requests for all drugs that require PA to: Note: Telephone requests for PA will be accepted only in the case of a medical emergency. MassHealth Drug Utilization Review Program P.O. Box 2586 Worcester, MA 01613-2586 1-800-745-7318 1-877-208-7428 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-9 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Prior Authorization (non-pharmacy services) Some services need prior authorization (PA). These items are identified in Subchapters 4 and 6 of your provider manual. Submit electronic PA requests using the Automated Prior Authorization System (APAS) at: www.masshealth-apas.com APAS technical support and training: 1-866-378-3789 Mail all paper PA requests, except those for personal emergency response systems (PERS) and those listed below for Massachusetts Commission for the Blind (MCB) and Community Case Management (CCM) members to: MassHealth ATTN: Prior Authorization Unit (include name of program area) 600 Washington Street Boston, MA 02111 Mail PA requests for MCB members for durable medical equipment, personal care attendant, private duty nursing (unless member is age 22 or over), and oxygen and respiratory therapy services to: Massachusetts Commission for the Blind 48 Boylston Street Boston, MA 02116 Mail PA requests for PERS to: The member’s local aging service access point (ASAP). See Appendix D in the Durable Medical Equipment Manual. Mail PA requests for Community Case Management members for nursing, home health aide, physical, occupational, and speech therapies, personal care attendant, durable medical equipment, oxygen and respiratory equipment to: Community Case Management P.O. Box 2586 100 Century Drive Worcester, MA 01613-2586 You may call the MassHealth PA Unit, CCM, ASAP or MCB, as applicable, to ask about the status of a PA request sent to one of the above addresses. Please wait the times specified in 130 CMR 450.303 before calling. PA requests not sent to CCM or MCB: 617-451-7000 1-800-862-8341 Community Case Management: 1-800-863-6068 PA for home health skilled nursing visits for MassHealth Basic members: 617-451-7132 MCB PA Unit: 617-727-5550 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-10 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Provider Enrollment and Credentialing MassHealth has contracted with MAXIMUS to manage provider enrollment and credentialing activities. Provider Enrollment and Credentialing establishes and maintains a file on every MassHealth provider. You must contact Provider Enrollment and Credentialing to report any changes in: -your licensure and certification; -Medicare provider status; -ownership information; or -any other qualifications that may affect your participation in MassHealth. You may contact Provider Enrollment and Credentialing by telephone to: -request a provider application; -ask about the status of your provider application; -verify your participation status; or -verify the information in your provider file. MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 Hours: Mon. – Fri., excluding holidays 8:00 A.M.-5:00 P.M. providersupport@mahealth.net You must write to Provider Enrollment and Credentialing on your letterhead stationery and include your MassHealth provider number and tax identification number to: -report changes in information, such as your provider -name and address; -change or add your Medicare provider number to your -MassHealth provider file; or -report a change in ownership. MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 Hours: Mon. – Fri., excludingholidays 8:00 A.M.-5:00 P.M. providersupport@mahealth.net To notify Provider Enrollment and Credentialing of any change in licensure, certifications, and qualifications or data that may affect participation in MassHealth: MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) Hours: Mon. – Fri., excluding holidays 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-11 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 To participate in the Primary Care Clinician plan (PCC), you must request a PCC plan enrollment and credentialing application from: MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) Hours: Mon. – Fri., excluding holidays 8:45 A.M. – 5:00 P.M. providersupport@mahealth.net Provider Training For all providers, except pharmacy providers, MassHealth has contracted with MAXIMUS to perform provider services, including training. To schedule a training or an individual consultation about billing for MassHealth services: MassHealth Provider Training P.O. Box 9118 Hingham, MA 02043 617-988-8974 (fax) providersupport@mahealth.net For pharmacy providers, MassHealth has contracted with ACS to perform provider services, including training. To schedule a training or individual consultation about billing for MassHealth pharmacy services: ACS State Healthcare ATTN: MassHealth 131 Tremont Street, 4th Floor Boston, MA 02111 617-423-1237 617-423-9846 (fax) masshealth.providerrelations@acs- inc.com Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-12 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Publications The following is a list of sources where requests can be directed for various MassHealth publications. Please submit written request on your company letterhead and include your provider number, tax identification number, and street address. Please note that the first replacement copy of a provider manual is provided free of charge. There will be a charge for additional copies. All current MassHealth regulations and bulletins are available for viewing on the MassHealth Web site at www.mass.gov/masshealthpubs. These regulations can also be found in Subchapter 6 (Service Codes) of provider manuals, where available. Provider manuals MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) Hours: Mon.– Fri., excluding holidays 8:00 A.M.-5:00 P.M. providersupport@mahealth.net REVS provider manuals To download a copy: WebREVS www.massrevs.eds.com POPS payer sheets ACS State Healthcare ATTN: MassHealth 365 Northridge Center 1 Suite 400 Atlanta, GA 30350 Transmittal letters, provider bulletins, and *billing instructions *Billing instructions are currently not available on line. Requests must be made in writing. Include your provider number, address, telephone number, the exact title of the publication, and the date of the issuance. Available on line at www.mass.gov or by writing to: MassHealth ATTN: Publications P.O. Box 9118 Hingham, MA 02043 617-988-8973 (fax) providersupport@mahealth.net Claim forms, prior authorization forms (including pharmacy), and other forms and publications Requests must be made in writing. Include your provider number, address, telephone number, and the exact title of the form. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 617-988-8974 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-13 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Fee schedules It is helpful if you know the Code of Massachusetts Regulations (CMR) citation that applies to your provider type. There is a charge for each publication. DHCFP also has the regulations available on disk. Please write to the State Bookstore address if you cannot access the Internet. Division of Health Care Finance and Policy (DHCFP) 2 Boylston Street Boston, MA 02116 617-988-3100 www.mass.gov/dhcfp State Bookstore State House, Room 116 Boston, MA 02133 617-727-2834 ICD-9-CM, CPT, and HCPCS Code Books are available from the following sources: (Have your credit card ready. In addition, ICD-9-CM Code Books are available from some bookstores.) Ingenix 13931 Willard Road Chantilly, VA 20151 1-800-765-6588 801-536-1009 (fax) American Medical Association Order Department P.O. Box 930876 Atlanta, GA 31193-0876 1-800-771-7199 863-582-6845 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-14 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Third-Party Liability Medicare/Senior Plan Updates MassHealth’s Medicare Unit maintains the file that identifies Medicare or a third-party liability (TPL) senior plan that a member may have. If you receive written evidence (such as a health insurance card) that a member has Medicare or a senior plan/Medicare replacement policy, has a different insurance than what is listed on the file, or no longer has insurance coverage, please send the information to the Medicare Unit. This does not apply to a member whose benefits have been exhausted, only to members who have terminated their enrollment, or transferred to another senior plan. Mail or fax the insurance information to: (Please enclose copies of written evidence, if possible.) MassHealth Medicare Unit 600 Washington Street Boston, MA 02111 617-210-5249 (fax) Other Health Insurance MassHealth’s TPL Unit maintains the file that identifies other health insurance that a member may have. Other insurance information comes from various sources. If you receive written evidence (such as an explanation of benefits or a letter from an employer) that a member has other health insurance, different insurance than what is listed on the file, or no longer has health insurance coverage, please send the information to the TPL Unit. Mail or fax the insurance information to: (Please enclose copies of written evidence, if possible.) MassHealth TPL Unit P.O. Box 9209 Boston, MA 02209 617-357-7604 (fax) Commercial Explanation of Benefits (EOB) Home health providers may no longer send MassHealth a single annual EOB for services denied by a commercial insurer. They must obtain and send an EOB whenever a member with commercial health insurance has a change in medical condition or health-insurance-coverage status. Providers must submit the EOB to MassHealth within 10 days of receiving notification of denial from the insurer. The EOB must include the member’s MassHealth identification number. Mail or fax a copy of the EOB to: MassHealth Kim Roussin LSW Home Health Claims 600 Washington Street Boston, MA 02111 617-210-5080 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-15 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 Vision Care Materials If you are a vision-care provider and need to check the status of an order for vision-care materials: MassCor Optical Labs P.O. Box 466 Gardner, MA 01440 1-888-323-5995 1-888-698-2020 (fax) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX A: DIRECTORY PAGE A-16 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-136 DATE 11/01/05 This page is reserved.