Billing timelines and appeal procedures

Timeline for providers who want to appeal claims that have been denied

This information is for you if you are a provider and 

• You need to submit a claim
• You have submitted a claim
• The claim has been denied
• You want to ask for a 90-day waiver, or
• You want to appeal the denied claim

Review the Timeline to understand when you must submit claims and when you can appeal. There is additional information about the appeal procedures you need to follow if you received an error code for 'Final Deadline Exceeded.'

All Provider Bulletin 232 contains additional detail about MassHealth's appeal submission procedures. PDF | Word

All Provider Bulletin 300: Final Deadline Appeals Board Electronic Correspondence, details the method of correspondence when submitting a final deadline appeal. PDF | Word

Timelines

30 days	Average time for both electronic (EDI) and paper claims to process on a remittance advice (RA).
60 days	Usual turnaround time for Medicare/MassHealth crossover claims forwarded to MassHealth by the Massachusetts Medicare fiscal agent to be processed.
90 days	Initial claims must be received by MassHealth within 90 days of the service date. If you had to bill another insurance carrier before billing MassHealth, you have 90 days from the date of the explanation of benefits (EOB) of the primary insurer to submit your claim.
12 months	Final submission deadline. You have 12 months from the date of service to resolve your claim, if you originally submitted the claim within 90 days from the date of service. If you exceed this deadline, your claim will be denied for error code 853 or 855 (Final Deadline Exceeded) on an RA. See the following section for the appeal procedures for these error codes
18 months	Final submission deadline if you had to bill another insurance carrier before billing MassHealth. You have 18 months from the service date to resolve your claim, as long as the claim was received by MassHealth within 90 days of the EOB date. If you exceed this deadline, your claim will be denied for error code 853 or 855 (Final Deadline Exceeded) on an RA. See the following section for the appeal procedures for these error codes
36 months	If the date of service is more than 36 months when it is received by MassHealth, the claim will be denied for error 856 or 857 (Date of Service Exceeds 36 Months) on an RA. A claim with this error code cannot be appealed.

Appeal procedures for error codes 853 or 855 ('Final Deadline Exceeded')

To be eligible for appeal, your claim must have been denied for error code 853 or 855 (Final Deadline Exceeded). You must file the appeal within 30 days of the date that appears on the remittance advice on which your claim first denied with error code 853 or 855. In order for your appeal to be approved, you must demonstrate that the claim was denied or underpaid as a result of a MassHealth error, and could not otherwise be timely resubmitted.

To file an appeal, you must submit the final deadline appeal request electronically via Direct Data Entry. See All Provider Bulletin 232, below. 

If you have a current approved electronic claim submission waiver, you can submit your appeal on paper. You will need to send us 

• a cover letter to include a valid e-mail address
• corrected claim form
• all the remittance advices the claim has appeared on (including the 853/855 denial), and
• any other supporting documentation

Send these materials to the following address.

MassHealth
ATTN: Final Deadline Appeals Unit
100 Hancock Street, 6th Floor
Quincy, MA 02171

Any inquiry about the status of your appeal request should be directed to [e-mail] or by calling [phone].

Additional Resources

All Provider Bulletins

All Provider Bulletin 300: Final Deadline Appeals Board Electronic Correspondence

All Provider Bulletin 300: Final Deadline Appeals Board Electronic Correspondence

All Provider Bulletin 232: Revisions to the Final Deadline Appeal Procedures

All Provider Bulletin 232: Revisions to the Final Deadline Appeal Procedures