: Individual Consideration The MassHealth agency may identify certain services as requiring individual consideration (I.C.) in program regulations, associated lists of service codes and service descriptions, billing instructions, provider bulletins, and other written issuances from the MassHealth agency. For services requiring individual consideration, the MassHealth agency establishes the appropriate amount of payment based on the standards and criteria set forth in 130 CMR 450.271(B). Providers claiming payment for any I.C.-designated service must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that must minimally include where applicable, but is not limited to, an operative report, pathology report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for “I.C.” services unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim. The MassHealth agency determines the appropriate payment for an I.C. service in accordance with the following standards and criteria: the amount of time required to perform the service; the degree of skill required to perform the service; the severity and complexity of the member's disease, disorder, or disability; any applicable relative-value studies; and any complications or circumstances that the MassHealth agency deems relevant. (130 CMR 450.272 through 450.274 Reserved)
: Claims Except as provided in program regulations, a claim for a medical service may be submitted only by the provider that provided the service. In the absence of a specific exception or qualification, 130 CMR 450.301(A) and (B) apply. An individual practitioner may not claim payment under his or her own name and provider ID/service location number for services actually provided by another individual, whether or not the individual who provided the service is also a participating provider, or is an associate, partner, or employee of the individual practitioner. An individual practitioner may not payment under his or her own name and provider ID/service location number for medical services provided by the individual practitioner and for which the practitioner is paid by another entity (for example, hospital, clinic, facility, pharmacy, home health agency, health maintenance organization, community health center, psychiatric day treatment program, day habilitation center, and adult day care center). In such cases, payment may be claimed only by the institution or facility. A provider may submit claims only if the payment for the services claimed is not otherwise claimed by any other MassHealth provider; and payment or any other compensation for the delivery of such services is not received by any provider from any other source. : 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. Paper Claims. 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. 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. Waiver Criteria. The MassHealth agency grants a provider an electronic claim submission waiver if any of the following criteria apply. The provider has submitted an average of fewer than 20 claims per month over the previous 12 months. The provider is experiencing temporary technical difficulties related to upgrading their current billing system or installing a new one. The provider is experiencing temporary technical difficulties related to testing or interfacing with the MassHealth agency’s claims processing system. The provider does not have Internet access or a computer. The provider is experiencing temporary disruption in service, for at five business days, caused by a natural disaster or utility work.