130 CMR 450.302 - 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.
(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.
Notes
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No prior version found.