130 CMR 450.309 - Time Limitation on Submission of Claims: General Requirements
(A) In accordance with M.G.L. c. 118E, ยง
38, all claims must be received by the MassHealth agency within 90 days from
the date of service or the date of the explanation of benefits from another
insurer. When a service is provided continuously on consecutive dates, the date
from which the 90-day deadline is measured is the latest date of
service.
(B) For claims that are
not submitted within the 90-day period but that meet one of the exceptions
specified below, a provider must request a waiver of the billing deadline (a
90-day waiver) pursuant to the billing instructions provided by the MassHealth
agency. The exceptions are as follows:
(1) a
medical service was provided to a person who was not a member on the date of
service, but was later enrolled as a member for a period that includes the date
of service;
(2) a medical service
was provided to a member who failed to inform the provider in a timely fashion
of the member's eligibility for MassHealth; and
(3) other exceptions that are expressly
authorized by the MassHealth agency pursuant to a MassHealth transmittal letter
or provider bulletin.
(C) When a medical service was provided to a
MassHealth member in another state by a provider that is not enrolled in
MassHealth, the MassHealth agency will consider a claim for such service to
have been timely submitted if all of the following apply:
(1) the medical service was provided in
accordance with 130 CMR 450.109;
(2) the provider submits an application to
the MassHealth agency to become a participating provider within 90 days after
the date of service and the MassHealth agency approves the application;
and
(3) the provider submits the
claim for payment within 90 days after the date of the notice from the
MassHealth agency approving the provider's application.
(D) All requests for waivers of the billing
deadline submitted to the MassHealth agency for review must be submitted
electronically in a format designated by the MassHealth agency, unless the
provider has been approved for an electronic claim submission waiver as
specified in
130 CMR
450.302(A)(3).
Notes
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