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Submit a 90-day Claim Waiver Request Form

MassHealth must receive your initial claim within 90 days of the service date. If you cannot meet this requirement, you can ask for a 90-day waiver for certain conditions that are described in the Administrative and Billing Regulations, at 450.309.

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The Details of Submit a 90-day Claim Waiver Request Form

What you need for Submit a 90-day Claim Waiver Request Form

As outlined in All Provider Bulletin 233, February 2013, 90-day waiver requests must be submitted electronically unless the provider has an approved electronic claim submission waiver. 90-day waiver requests must be submitted electronically via the Provider Online Service Center (POSC) direct data entry (DDE) using the attachments tab and the appropriate HIPAA delay reason code(s).

Each individual 90-day waiver claim must be submitted with supporting documentation that is relevant to that claim. If you are submitting multiple claims for the same member and for the same delay reason, each claim must be submitted separately with a 90-day waiver request form and the respective documentation. These documents must be scanned and included with the DDE claim submission.

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 the following delay reason codes may be used when submitting 90-day waiver claims.

1 – Proof of Eligibility Unknown or Unavailable
4 – Delay in Certifying Provider
8 – Delay in Eligibility Determination

If your claim requires a 90-day waiver for reasons other than 1 or 4, please use delay reason code 8 and explain the reason for the delay. Please note (cont.) 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 90-day waiver requests as instructed may result in your waiver request not being reviewed or being denied.

Claims submitted with 90-day waiver requests will initially appear in a suspended status on your remittance advice for Edit 818-Special Handling 90-day waiver. Ninety-day waiver decisions will be reflected on a subsequent remittance advice, once the claims have been fully adjudicated.

How to file Submit a 90-day Claim Waiver Request Form

For non-pharmacy providers

  • Submit 90-day waiver requests via direct data entry (DDE) on the Provider Online Service Center (POSC).
  • With each claim, include a copy of all remittance advices (RAs) where the claim has appeared, if applicable.
  • Submit all supporting documentation with each claim, such as copies of retroactive enrollment notices.
  • Submit the 90-Day Waiver Request Form with each claim stating the reason for the waiver request.
  • Enter the appropriate delay reason code corresponding to your 90-day waiver. For professional claims, use the drop down box on the Extended Services tab in the POSC. For institutional claims, use the drop down box on the Billing and Service tab.

For pharmacy providers

For dental providers

  • Submit 90-day waiver requests via the MassHealth Dental Provider Portal using the Contact Us link to create an inquiry.
  • As an attachment to the inquiry, the provider must submit the 90-day waiver request on office letterhead. Include the claim Internal Control Number (ICN), if applicable, the reason for the request, and supporting documentation.
  • We will consider claims that are not submitted within the 90-day period if they meet one of the following exceptions:
    • The service was provided to a person who was not a MassHealth member on the date of service but was late enrolled into MassHealth for a period that includes the date of service; OR
    • The service was provided to a member who failed to inform the provider of his or her active enrollment in MassHealth.

More info for Submit a 90-day Claim Waiver Request Form

For all non-pharmacy claims

You can request a 90-day waiver when one or more of the following conditions apply and the claim is not currently pended, paid, or suspended. You must provide necessary documentation with each claim.

  • The member or provider was retroactively enrolled with MassHealth.
  • The member did not inform the provider of the member’s enrollment with MassHealth within 90 days of the date of service.
  • The provider is making a change to the member’s MassHealth ID number on a claim that was originally submitted within the time limits defined in MassHealth regulations at 130 CMR 450.309 and 450.313.
  • The provider is making a change to the pay-to-provider number on a claim that was originally submitted within the time limits defined in MassHealth regulations at 130 CMR 450.309 and 450.313.
  • You are billing the claim for the first time, and meet the criteria outlined in MassHealth regulations at 130 CMR 450.309 through 450.313.

The following circumstances do not require a 90-day waiver:

  • Claims that will be received within 90 days from the date on a third-party payer’s EOB and still within 18 months of the service date; and
  • Claims that can be resubmitted according to the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual.

For pharmacy claims

You should use the 90-day Waiver Form for all requests to waive the requirement that you submit given claims within 90-days of the date of service.

If you have an approved electronic claim submission waiver, then you may submit a paper 90-day waiver request.

What you need

90-Day Waiver Request Form [90-DWR]

You can ask for a 90-day waiver for certain conditions that are described in the 90-Waiver Request Form.

Downloads for Submit a 90-day Claim Waiver Request Form

Contact for Submit a 90-day Claim Waiver Request Form

Phone

This number is not for verifying member eligibility. Please use the POSC to verify member eligibility.

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