Duplicate Claims Suspension – Independent Nurse (IN) Providers

In August of 2024, MassHealth implemented the following claims detections:

1. 1. 1. If an Independent Nurse (IN) bills for overtime units using modifiers TU or U4 before they bill for 40 hours of standard Continuous Skilled Nursing (CSN) services in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).
      2. If an IN bills for greater than 20 hours of overtime units using modifiers TU or U4 in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).
      3. If an IN bills for greater than 60 hours of CSN services (using any procedure code or modifier) in a calendar week (starting Sunday 12am and ending Saturday 11:59pm).

After these claim detections went into effect, MassHealth saw an increase in duplicate claims. This occurs when a provider resubmits a claim. On November 3, MassHealth began suspending all duplicate claims for manual review. If you are resubmitting suspended claims, those additional claims will also be suspended and will be reviewed manually. To try to reduce suspended claims, please abide by the following guidance:

1. 1. 1. Do not resubmit a suspended claim.
      2. Do not submit multiple claims for the same date of service. If you worked multiple shifts on the same date of service or you worked both daytime and nighttime hours, include all units on the same claim and differentiate using different claim lines.

If you have questions, please contact the LTSS Provider Service Center at (844) 368-5184 or support@masshealthltss.com.