MassHealth Billing and Claims - Claims Submission

This is a part of the MassHealth Provider Handbook.

Eligibility Verification Reminder

Eligibility must be verified prior to providing service. By verifying a member’s eligibility on the day or date range of service, providers may be able to reduce the risk of their claims being denied due to eligibility. EVS messages indicate health plan information for accurate submission. Dental providers need to follow additional requirements as outlined in the MassHealth Members and Benefits section of the handbook.

Claims Submission

• For PCC plan and Primary Care ACO members, please submit electronic only claims* directly to MassHealth except for behavioral health (BH).
• BH claims should be submitted directly to MBHP.
• For Managed Care Organization (MCO) members, please submit claims directly to the MCO.
• For Accountable Care Partnership Plan members, please refer directly to the applicable Accountable Care Partnership Plan for claims submission instructions.
• Dental and Pharmacy claims should not be sub- mitted through POSC.

*Per MassHealth All Provider Bulletin 225 (April 2012), effective January 1, 2012, all claims must be submitted electronically. Only providers who have received an approved electronic waiver may submit paper claims. Please reference the EDI section of this handbook for more information regarding electronic transmissions.

Dental Claims

All dental claims must be submitted electronically (unless you have a claims paper waiver on file) directly to DentaQuest via the following methods:

• Electronic claims via direct data entry at www.masshealth-dental.net. This is a secure, HIPAA-compliant, direct data-entry option. Please contact the EDI team at [e-mail] to ensure your practice has the necessary software to generate a HIPPA compliant 837D file, requirements for set-up are reviewed, necessary configuration takes place and testing of transaction involved is completed.
• Electronic claims in the HIPAA-compliant 837D format via upload to our secure trading partner portal is available at www.masshealth-dental.net.
• Electronic submission via a clearinghouse partner using payer ID CKMA1.
• Electronic submission MassHealth Provider Web Portal.
• Paper claims on the ADA 2012 or newer claim form only for those providers who have an approved electronic claim submission waiver on file with MassHealth/DentaQuest.

Please refer to the MassHealth Dental Office Reference Manual located in the documents section of the provider web portal.

For dental general billing, claims, member eligibility questions or training requests reach out to the MassHealth/DentaQuest customer service center at (800) 207–5019 or email customer service at [e-mail].

Oral Surgeons — Billing Medical

All participating oral surgery providers are obligated to bill MassHealth for dental and medical covered services.

Oral surgeons must complete the enrollment process to bill for covered oral surgery CPT/medical codes via MassHealth’s Provider Online Service Center (POSC) by filling out the Data Collection Form and Registration Instruction and e-mailing it to [e-mail] in order to gain access.

For medical general billing or claims questions reach out to the MassHealth/Maximus customer service center at [phone] or email questions to [e-mail].

Timely Submissions

Initial claims must be received by MassHealth within 90 days of the service date. If the member has other insurance, the provider must bill the other insurance carrier before billing MassHealth and the claim must be submitted within 90 days from the date of the explanation of benefits (EOB) of the primary insurer. For claims that are not submitted within the 90-day period but that meet one of the exceptions specified in section 450.309 B of the Administrative and Billing Regulations, a provider must request a waiver of the billing deadline (a 90-day waiver) pursuant to the billing instructions provided by MassHealth, refer to MassHealth All Provider Bulletin 233 dated February 2013.

Electronic claim submission options available to providers:

• Direct billing — direct upload of EDI batch claims files through POSC;
• Vendor (billing intermediary or clearinghouse) that submits claims on your behalf, and
• Direct Data Entry (DDE) of claims though the Provider Online Service Center.

Final submission of a claim is 12 months from the date of service or 18 months from the date of service if the member has another insurance carrier billed prior to MassHealth. For more information on Final Deadline Appeals, please see All Provider Bulletin 232 dated February 2013 and All Provider Bulletin 300 dated September 2020.

Learn more about billing timelines and appeal procedures.

Claim Attachments

For certain services, MassHealth requires other forms and documentation. Some services require submission of an attachment with the claim, while others may require such documentation to remain on file in the member’s medical record. See the applicable program regulations in the MassHealth provider manual for specific report requirements. Attachments that must be submitted with the claim must be submitted using DDE only. Some services that require a submission of an attachment must be submitted with a Delay Reason Code. Please refer to the applicable provider type Administrative and Billing Regulations 130 CMR 450.000.

Date published:	July 29, 2022