MassHealth HIPAA EDI Testing Process

Learn about the testing process for electronic transactions.

This page describes the approach MassHealth uses to support trading partner testing with new and existing MassHealth providers. MassHealth uses a testing environment to perform end-to-end electronic transaction testing.

Before you start

Before you can test, you must be enrolled as an active provider with MassHealth. Once you are enrolled, you may then request to have transactions set up and request testing for those transactions, if needed.

Call the MassHealth Customer Service Center at [phone], TDD/TTY: 711 if you need to enroll or have questions about being an active MassHealth provider. If you are enrolled and ready to test, please send an email to the MassHealth EDI team at [e-mail].

You must contact the EDI unit by email before submitting any test files. Any test files submitted without prior knowledge and coordination by the EDI unit will not be monitored for review of results.

What you'll need

When you contact MassHealth's EDI Unit, the EDI representative will need the following information to coordinate the test.

1. Name and associated contact information, including email and phone number.
2. Username - Call us at [phone], TDD/TTY: 711 if you do not have a user ID or do not know it. Validate that the username has access to the provider ID of the provider who wants to test and the proper role authorities for the production environment (for example, claims submission, manage member eligibility, batch file submit, and download).
3. Provider ID - If you are a provider and do not have a provider ID, call us at [phone], TDD/TTY: 711. If you are a billing intermediary or software vendor, contact your client to get their provider ID.
4. Submitter ID (if applicable).
5. Type of transaction(s) you want to test.
6. 837I & 837P Health Care Claim: Institutional/Professional
7. 835 Health Care Payment/Advice - We do not test 835 remittance advices, but we can validate the results on file.
8. Date you anticipate you will need to start testing.
9. Date you need to complete testing (if applicable).

If you are submitting a transaction to MassHealth, your transactions will be processed against our testing environment. You must submit 10–15 (50 if you are a billing intermediary or clearinghouse) transactions to provide a representative set of the various types of business conducted for the site. The MassHealth Customer Service Center will be required to review, monitor, and respond to file submissions much as they currently do in standard TPT until the provider reaches the standard threshold (80% of claims pass) to complete trading partner testing.

Steps to follow to ensure successful testing with MassHealth

Step 1

You must inform MassHealth's EDI unit that you want to test electronic X12 transactions with MassHealth. If you plan to submit with an approved billing intermediary, you do not have to test with MassHealth directly.

However, if you are using a billing intermediary, we highly recommend that you coordinate testing with your billing intermediary to ensure that your claims are accepted. If you are using a software vendor, you must test with MassHealth directly. You must provide the information listed under “What you’ll need” before testing can begin with your billing intermediary or software vendor.

Contact the MassHealth EDI unit by email at [e-mail].

 

Step 2

MassHealth will update your testing profile in MMIS so that we can track the results of the testing process with you. MassHealth will update your provider file in MMIS to ensure the following.

• The trading partner is authorized to submit production transactions once they pass testing.
• The relationship links between the provider and any billing agency are established and noted in MMIS. It is the responsibility of the provider to request such links. This may include setting up an alternative submitter ID for claims or an alternative receiver ID for the 835.
• If you intend to submit void, replace, and COB claims as part of your normal course of business with MassHealth, those types of claims must be included in the provider's test sample.
• NPI and taxonomy are set up correctly. (Taxonomy is only required when deemed necessary by MassHealth.)

 

Step 3 

The trading partner should notify the MassHealth EDI team when a file is submitted. You should inform EDI of the date you submitted the file, the username that uploaded the file, and the submitter ID.

• The MassHealth EDI team will monitor the test based on the day the file was submitted and the receipt names that you identify are on the test file.
• Complete validation for pre-compliance (validates the first level of compliance) and validation for compliance (provider will receive 999). If you do not receive a 999, then the file did not pass HIPAA pre-compliance, as there may be an issue with the ISA used on the transaction. For example, test files submitted with ISA 15 = "T" in this production environment will be rejected and a 999 will not be generated. The MassHealth Customer Service Center will contact you about the error.
• If a file fails compliance, the MassHealth EDI team will track the results, contact you, and work with you to correct the issues.
• If a file passes compliance and reaches adjudication, the MassHealth EDI team will review the file, discuss the results with you, and identify any file-related changes that need to be made for future submissions. A minimum of 80% of claims must pass. If you have multiple service locations, it is in your best interest to view the remittance advice and verify that the claims are processing to the correct location. All test results will be communicated to the trading partner and documented by the MassHealth EDI team.
• If you have any questions about this process, please contact the MassHealth EDI team at [e-mail].

Date published:	March 13, 2024