Message Text – November 2025

MassHealth Provider Remittance Advice

The messages listed below may be general All Provider messages, applicable to several provider types or services, or provider specific. 

You can request a copy of a prior message by:

• Emailing [e-mail]
• Sending a letter to

  MassHealth Customer Service
  P.O. Box 278
  Quincy, MA 02171

• Calling MassHealth Customer Services at [phone],
  Hours: Monday through Friday 8 a.m. to 5 p.m.

11/25/2025

MassHealth EDI Inquiry Online Tool

MassHealth is introducing a new Electronic Data Interchange (EDI) Inquiry Request form which will be accessible on Mass.gov in order to streamline how providers submit EDI related inquiries.

Beginning later this month, all MassHealth providers will be required to use this online form for billing vendor updates, direct submission requests, and issues related to submitting or receiving EDI files. The EDI Inquiry form is designed to save time, ensure requests reach the MassHealth EDI team with complete information, and provide clear step-by-step guidance throughout the submission process.

Providers may access the EDI Inquiry Request form now available on mass.gov.

If you have questions, please contact MassHealth at [e-mail] or [phone].

Advancing Interoperability and Improving Prior Authorization Processes

On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes Final Rule (the “Final Rule”). The Final Rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients, healthcare providers, and payers. The Final Rule also focuses on efforts to improve prior authorization (PA) processes through policies and technology, to help ensure that patients remain at the center of their own care.

The Final Rule requires MassHealth to adjudicate standard PA requests under the medical benefit within 7 calendar days and expedited PA requests under the medical benefit within 72 hours. The expected implementation date for this is January 1, 2026.

The Final Rule requires that MassHealth make certain health care information, such as claims information, available to MassHealth members through the Patient Access Application Programming Interface (API). Beginning January 1, 2026, members will be able to access their health information from January 1, 2016, with a third-party application of their choice.

On November 20, 2025, MassHealth issued the All Provider Bulletin 413 and published the MassHealth’s Implementation of Interoperability and Prior Authorization Requirements web page which includes more details about PA process changes that are effective January 1, 2026.

MassHealth plans to conduct a series of information sessions in December 2025, to provide an overview of the upcoming changes to the PA processes and Medicaid Management Information Systems (MMIS) Provider Online Service Center (POSC) modifications. MassHealth providers impacted by these changes are encouraged to participate in the information sessions.

For questions or concerns:

LTSS providers, please contact the LTSS Provider Service Center at [phone] or [e-mail].

All other providers, please contact MassHealth at [phone] or [e-mail].

11/11/2025

Duplicate Claims Suspension - Independent Nurse (IN) Providers

In August of 2024, MassHealth implemented the following claims detections:

1. If an Independent Nurse (IN) bills for overtime units using modifiers TU or U4 before they bill for 40 hours of standard Continuous Skilled Nursing (CSN) services in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).
2. If an IN bills for greater than 20 hours of overtime units using modifiers TU or U4 in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).
3. If an IN bills for greater than 60 hours of CSN services (using any procedure code or modifier) in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).

After these claim detections went into effect, MassHealth saw an increase in duplicate claims. This occurs when a provider resubmits a claim. On November 3, MassHealth began suspending all duplicate claims for manual review. If you are resubmitting suspended claims, those additional claims will also be suspended and will be reviewed manually. To try to reduce suspended claims, please abide by the following guidance:

1. Do not resubmit a suspended claim.
2. Do not submit multiple claims for the same date of service. If you worked multiple shifts on the same date of service or you worked both daytime and nighttime hours, include all units on the same claim and differentiate using different claim lines.

If you have questions, please contact the LTSS Provider Service Center at [phone] or [e-mail].

11/04/2025

Overpayments Resulting from Duplicate Claim Editing Issue

MassHealth has identified an editing issue that has resulted in overpayments for several providers. The issue has been corrected, and we are in the process of identifying affected claims for a Mass Adjustment to recoup the overpayments.

As a reminder, duplicate billing is forbidden according to MassHealth Billing Regulation 130 CMR 450.307: Unacceptable Billing Practices. Please refer to the All Provider Administrative and Billing Regulations for additional information.

If you have questions, please contact MassHealth at [e-mail] or [phone].

Date published:	November 3, 2025