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Clarification for Institutional Claims for Ordered/Referred Services

July 9, 2018

All Provider Bulletin 274, posted on 02/08/2018, was released with the intent to assist billing providers as they prepare their processes and systems for compliance with MassHealth's Ordering, Referring, and Prescribing (ORP) requirements, and to reduce the impact once claim denials take effect.  MassHealth is preparing for, but has not yet established, a date to begin denying claims that do not meet the ORP requirements. MassHealth will communicate the start date for claim denials prior to beginning such denials. 

837I claims require the NPI of the Attending Provider in the Attending field/loop on the claims. For consistency with HIPAA Version 5010 billing instructions, when submitting 837I claims to MassHealth for ordered/referred services, the NPI of the Ordering/Referring provider is not required in the Referring field/loop when the Ordering/Referring provider is the same as the Attending Provider. Billing providers may choose to include the NPI of the Ordering/Referring provider in the Referring field/loop if the providers are the same but are only required to do so if the providers are different.

If you have any questions, please contact the MassHealth Customer Service Center at 1-800-841-2900 or e-mail providersupport@mahealth.net.

If you are an LTSS Provider and have any questions, please contact the MassHealth LTSS Provider Service Center at 1-844-368-5184 or e-mail support@masshealthltss.com.