Error message for edit 2016 has been updated to clarify denied claims where a member is enrolled in PACE/SCO. The updated message is 2016 MEMBER COVERED BY SCO/PACE PLAN – MUST BILL SCO/PACE. Providers are reminded to bill the SCO/PACE plan for services. For questions or concerns: LTSS providers, please contact the LTSS Provider Service… Continue Reading Edit 2016 Updated Error Message Description
Starting January 1, 2026, independent nurses (INs) who are seeking a prior authorization (PA) to work with a Community Case Management (CCM) member for the first time must submit a copy of a signed plan of care to the member’s CCM clinical manager in order to receive their PA for continuous skilled nursing (CSN) services.… Continue Reading Plan of Care Submission Requirements
MassHealth will be implementing a new claims detection on January 12, 2026, to ensure that dates of service (DOS) for claims submitted by independent nurses fall within one calendar week. A calendar week is defined as the hours from 12 am Sunday to 11:59 pm Saturday. This claims detection is being used to ensure that… Continue Reading New Claim Detection for Independent Nurses
To allow for system maintenance, the MMIS POSC, Provider Portal, HTS transactions, internal MMIS application, EVS and all eligibility services will be unavailable on Sunday, December 28, 2025, from 3:00 PM to 10:00 PM. MAP, CBHI, MeNoB, member and eligibility web services and Netreveal predictive modeling application servers will also be impacted. We apologize for… Continue Reading MMIS System Outage Notice – Sunday, December 28, 2025
MassHealth has completed the rate updates for the July 1, 2025 and October 1, 2025 Quarterly Drug Code Rates of the Community Health Center Manual. MassHealth updated its system for these drug code rate changes effective for dates of services on or after July 1, 2025, and October 1, 2025. All affected claims were reprocessed… Continue Reading Claims Reprocessed for Community Health Centers for Updated July 1, 2025 and October 1, 2025 Quarterly Drug Code Rates
MassHealth is seeing large numbers of denials for 1945 – BILLING PROVIDER NPI IS MAPPED TO MULTI SERV LOC when the NPI cannot be mapped to the correct MassHealth Provider ID/Service Location (PID/SL). Providers are reminded of the following to avoid these denials: Do not bill with a taxonomy code in the 2000A PRV03 segment… Continue Reading Claim Denials – Billing Provider HPI is Mapped to Multiple PID/SLS
MassHealth identified that certain Community Behavioral Health Center (CBHC) claims for Medicare Savings Plan (MSP) members (formerly known as Senior Buy-in) were incorrectly denied for edit 2609 “SBI benefit plan – not a covered service”. Specifically, claims billed to MassHealth for the CBHC clinic per diem bundle that included a payment and/or patient responsibility from… Continue Reading Reprocessing Community Behavioral Health Center (CBHC) Claims Denied in Error
MassHealth identified an issue that caused incorrect pricing on certain group practice Medicare crossover claims, leading to overpayments. This occurred when the rendering provider was a mid-level practitioner and the place of service was 02 or 10 (telehealth). The issue has been resolved, and all impacted Medicare crossover claims adjudicated on or after February 1,… Continue Reading Adjusting Certain Group Practice Medicare Crossover Claims
Effective December 1, 2025, Provider Expiration Notices for Provider Requests for Transportation (PT-1s) will no longer be mailed. Please continue to monitor the Upcoming Expirations tab within the Customer Web Portal (CWP) for updates on existing PT-1 status: https://masshealth.ehs.state.ma.us/CWP/Default. If you have questions, please contact MassHealth at provider@masshealthquestions.com or (800) 841-2900. LTSS providers, please contact… Continue Reading Mailing Discontinued for PT-1 Provider Expiration Notices
MassHealth implemented edit 9974 “PM: deny-service not covered/payable by MassHealth” in May 2025 to deny crossover claims billed with modifier JW ‘drug amount discarded/not administered to any patient’. Use of this modifier is not permitted under MassHealth policy, as outlined in Subchapter 6 of the Provider Manual. In October 2025, MassHealth identified a system issue… Continue Reading Adjustments on Medicare Crossover Claims for Discarded Drugs
