![]() Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. ![]() ![]() By clicking on “I Accept”, I acknowledge and accept that: Send these materials to the following address.Īny inquiry about the status of your appeal request should be directed to or by calling (617) 847-3115. all the remittance advices the claim has appeared on (including the 853/855 denial), and.a cover letter to include a valid e-mail address.If you have a current approved electronic claim submission waiver, you can submit your appeal on paper. To file an appeal, you must submit the final deadline appeal request electronically via Direct Data Entry. In order for your appeal to be approved, you must demonstrate that the claim was denied or underpaid as a result of a MassHealth error, and could not otherwise be timely resubmitted. You must file the appeal within 30 days of the date that appears on the remittance advice on which your claim first denied with error code 853 or 855. To be eligible for appeal, your claim must have been denied for error code 853 or 855 (Final Deadline Exceeded). A claim with this error code cannot be appealed.Īppeal procedures for error codes 853 or 855 ('Final Deadline Exceeded') ![]() If the date of service is more than 36 months when it is received by MassHealth, the claim will be denied for error 856 or 857 (Date of Service Exceeds 36 Months) on an RA. See the following section for the appeal procedures for these error codes If you exceed this deadline, your claim will be denied for error code 853 or 855 (Final Deadline Exceeded) on an RA. You have 18 months from the service date to resolve your claim, as long as the claim was received by MassHealth within 90 days of the EOB date. If you exceed this deadline, your claim will be denied for error code 853 or 855 (Final Deadline Exceeded) on an RA. See the following section for the appeal procedures for these error codesįinal submission deadline if you had to bill another insurance carrier before billing MassHealth. You have 12 months from the date of service to resolve your claim, if you originally submitted the claim within 90 days from the date of service. If you had to bill another insurance carrier before billing MassHealth, you have 90 days from the date of the explanation of benefits (EOB) of the primary insurer to submit your claim.įinal submission deadline. Initial claims must be received by MassHealth within 90 days of the service date. Usual turnaround time for Medicare/MassHealth crossover claims forwarded to MassHealth by the Massachusetts Medicare fiscal agent to be processed. Average time for both electronic (EDI) and paper claims to process on a remittance advice (RA).
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