Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.302 - Claim Submission

Current through Register 1525, July 5, 2024
(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.