Claim Submission

(A) (1) Electronic Claims. All claims submitted to the MassHealth agency for payment must be submitted electronically in a format designated by the MassHealth agency, unless the provider has been approved for an electronic claim submission waiver. (2) Paper Claims. (a) Any paper claims submitted by a provider who does not have an approved electronic claim submission waiver, pursuant to 130 CMR 450.302(A)(3), are rejected. (b) Any paper claims submitted by a provider who has an approved electronic claim submission waiver must be submitted on the claim form designated by the MassHealth agency and according to its administrative and billing instructions. (3) Waiver Criteria. The MassHealth agency grants a provider an electronic claim submission waiver if any of the following criteria apply. (a) The provider has submitted an average of fewer than 20 claims per month over the previous 12 months. (b) The provider is experiencing temporary technical difficulties related to upgrading their current billing system or installing a new one. (c) The provider is experiencing temporary technical difficulties related to testing or interfacing with the MassHealth agency’s claims processing system. (d) The provider does not have Internet access or a computer. (e) The provider is experiencing temporary disruption in service, for at least five business days, caused by a natural disaster or utility work. (f) The provider attests to the MassHealth agency that its staff responsible for claims submission have a disability that prevents the submission of electronic claims that cannot be easily mitigated with reasonable accommodation. 3. Billing Regulations (130 CMR 450.000) (g) The provider has an extenuating circumstance in which submitting electronic claims would impede the provider’s ability to participate in MassHealth. (4) Waiver Duration. An electronic claim submission waiver is valid for 12 months from the date of issue. Providers who continue to experience circumstances that necessitate a waiver must apply for another waiver at least 30 days before the expiration of their current waiver, in order to avoid a possible interruption in payment. (5) Waiver Fee. There is no fee for the first electronic claim submission waiver. The MassHealth agency may assess an administrative fee based on paper claim volume for any subsequent electronic claim submission waiver granted to a provider. (6) Waiver Request Review Process. After review of a provider’s request for an electronic claim submission waiver, the MassHealth agency notifies the provider in writing of its decision. If the waiver request is incomplete, the MassHealth agency may request additional information from the provider. If the provider does not submit the requested information to the MassHealth agency within 30 days of the request date, the MassHealth agency denies the waiver request. A provider may reapply for an electronic claim submission waiver with new or additional information. (B) All claims submitted by a group practice must clearly identify by provider ID/service location number the individual practitioner who actually provided the services being claimed. (C) A group practice may submit claims only for services provided by individual practitioners who are MassHealth providers and who have been enrolled and approved by the MassHealth agency as a participant in the group.