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.

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.