MassHealth Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 221 December 2011 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Revisions to the Final Deadline Appeal Procedures Background MassHealth has revised its claims submission procedures. Effective January 1, 2012, final deadline appeal requests may be submitted electronically via direct data entry (DDE) using the appropriate HIPAA delay reason code. Providers are encouraged to take advantage of electronic submission for their final deadline appeals to increase organizational efficiency. Pharmacy providers will continue to follow the final appeals process described in Appendix A of the POPS Billing Guide. This bulletin outlines the new procedures for the electronic submission of final deadline appeal requests using HIPAA delay reason codes. Important Note to Dental Providers: Oral and maxillofacial surgeons may now submit final deadline appeals electronically. Dental providers who are not oral or maxillofacial surgeons will continue to submit their final deadline appeals as referenced in Dental Bulletin 41 (May 2009). Submitting a Final Deadline Appeal A final deadline appeal must meet the criteria at 130 CMR 450.323(A) and include the documentation specified under 130 CMR 450.323(B) to substantiate the contention that the claim was denied or underpaid due to MassHealth error. These documents may be scanned and included with the DDE claim submission. Please be sure to use the attachments tab to upload all applicable documents related to the final deadline appeal request. For professional claims, providers must select the appropriate delay reason code from the drop-down box on the Extended Services tab of the POSC. For institutional claims, providers must select the appropriate delay reason code from the drop-down box on the Billing and Service tab. Only Delay Reason Code 9 may be used when submitting a final deadline appeal. Please note that for members with commercial insurance and/or Medicare coverage, the coordination of benefits information must be completed on the DDE transaction. Failure to submit the required documentation with your appeal request as stated above may result in the denial of the appeal. (continued on next page) MassHealth All Provider Bulletin 221 December 2011 Page 2 Decisions on Final Deadline Appeal Requests Final deadline appeal requests will initially appear in a suspended status on your remittance advice with Edit 828 (Claim/appeal is under review) while your request is being reviewed. The decision resulting from the review will be reflected on a subsequent remittance advice. If the final appeal is denied, one of the following edit codes will appear with the claim. 9086 - Denied after review 9087 - Insufficient information 9088 - Duplicate appeal request 9089 - The request does not meet the criteria at 130 CMR 450.323(A). Written notification of the approval or denial decision will be sent to the provider and constitutes the final agency action. Questions If you have any questions about the information in this bulletin or need help getting started with electronic claims submission, 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.