Message Text – October 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.

10/28/2025

Changes to MassHealth’s Accountable Care Organizations on January 1, 2026

As part of MassHealth’s annual Accountable Care Organization (ACO) program update process, there will be changes to ACO service areas, hospitals, providers, and health plans within the managed care program effective January 1, 2026. Please reference All Provider Bulletin 410 at 2025 MassHealth provider bulletins for more details.

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].

Electronic Visit Verification (EVV) Match Informational Explanation of Benefits (EOBs)

MassHealth EVV soft edits are now live, and you may see new EVV messages on your Remittance Advice (RA). For claims for EVV services processed through MassHealth, you may begin to see codes on your RA indicating whether a matching EVV visit was found in the Sandata EVV Aggregator for the EVV service on the claim. At this time, the existence of a matching or unmatching EVV visit is not affecting the MassHealth claims payment and is being supplied to aid providers in understanding where and why mismatches occur. This period of providing EVV match notification on the RA but not having EVV impact claims payment is called “EVV soft edits”. More information will be sent to EVV providers to provide guidance on these EVV specific edits and how to take corrective action. If you have general MA EVV policy related questions, please email [e-mail].

Reprocess Medicare Crossover Claims Incorrectly Denied with Edit 2502

MassHealth identified an issue affecting Medicare crossover claims billed for services that are unrelated to a hospice member’s terminal illness. These crossover claims were incorrectly denied for edit 2502 ‘Member covered by other insurance’ for members enrolled in a Medicare Advantage plan on the date of service. The affected crossover claims with dates of service on or after January 2023 have been reprocessed and will appear on subsequent remittance advices.

If you have questions regarding this message:

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].

Update for Quarterly Drug Code Rates Effective October 1, 2025

MassHealth has completed the rate updates for the October 1, 2025 Quarterly Drug codes. The impacted claims will be reprocessed and/or adjusted and will appear on a future remittance advice.

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

10/14/2025

Reprocess Behavioral Health Urgent Care (BHUC) Claims Incorrectly Denied with Edit 5125

MassHealth identified an issue affecting BHUC claims which caused claims to deny incorrectly with edit 5125 ‘Missing procedure on BHUC bundle claim’. The affected BHUC claims have been reprocessed and will appear on subsequent remittance advices.

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

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 emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients (members), healthcare providers, and payers. The rule also focuses on efforts to improve prior authorization processes through policies and technology, to help ensure that patients remain at the center of their own care.

This final rule requires MassHealth to adjudicate Prior Authorization requests (excluding drugs) within 7 calendar days, or 72 hours for expedited requests. The implementation date for this is 1/1/2026.

Beginning 3/31/2026, MassHealth will post prior authorization metrics to Mass.gov. The metrics will be updated on an annual basis.

This final rule requires impacted payers to implement and maintain a Patient Access Application Programming Interface (API), a Provider Access API, a Payer-to-Payer API, and a Prior Authorization API. The expected implementation date for the APIs is 1/1/2027.

MassHealth will be issuing an All-Provider Bulletin in the near future with details. Information sessions are also being planned and further details on these sessions will be made available soon.

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].

Date published:	October 14, 2025