Medical billing services in Massachusetts

Billing in Massachusetts: what's different

The rules below change how a claim is filed and paid in Massachusetts. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Massachusetts claims are billed

• Paper claims are rejected unless MassHealth has granted an electronic submission waiver⁴

  Under 130 CMR 450.302, every claim goes to MassHealth electronically in the format the agency designates. A paper claim from a provider without an approved electronic claim submission waiver is rejected outright, not pended. Waivers go to providers averaging fewer than 20 claims a month over the past 12 months, practices with temporary system upgrade or testing problems, offices without internet access or a computer, a disruption of at least five business days from a disaster or utility work, or a documented staff disability, and each waiver lasts 12 months, with renewal due 30 days before it ends. The first waiver is free; MassHealth may charge an administrative fee based on paper volume for later ones.

• 12 months, 18 months with other insurance, and 30 days to reach the Final Deadline Appeals Board⁴

  A claim denied inside the 90-day window can be corrected and resubmitted, but 130 CMR 450.314 bars payment for any service more than 12 months before the submission or resubmission. The exceptions are a claim held for another insurer, which is timely within 90 days of that insurer's final disposition and no later than 18 months after service, and an appeal to the Final Deadline Appeals Board, which hears only claims denied or underpaid through MassHealth agency error, filed within 30 days of the remittance advice that first denied the claim for passing the final deadline, with the original timely submission and every corrective step documented. Services more than 36 months old cannot be appealed at all.

• MassHealth is the payer of last resort, and it checks whether you tried the others⁴

  130 CMR 450.316 requires diligent efforts to collect from every other liable party before MassHealth pays, and the agency will recover a payment if it decides those efforts were not made. Diligent efforts include asking the member about other coverage, checking the Eligibility Verification System for other insurance on each date of service and again at billing, and submitting claims to each insurer. A member can never be billed for a covered service beyond what 130 CMR 450.130 allows, and a crossover payment is capped at the member's Medicare coinsurance, deductible and copayment, the MassHealth maximum allowable, or the MassHealth crossover rate, whichever applies.

• Unlisted CPT codes need the form, the records and delay reason code 11¹

  All Provider Bulletin 411 (October 2025) requires a claim with an unlisted CPT code to carry the Unlisted CPT Code Form from the MassHealth claim submission page plus medical records that explain the procedure, why no listed code fits, the time, effort and complexity involved, and the medical necessity. The claim is filed through the Provider Online Service Center with delay reason code 11 so it suspends for manual pricing. A claim that arrives without the form, the records or the delay reason code is denied.

• Chapter 141 of the Acts of 2000 rewrote carrier claim payment and created chapter 176O⁹

  The Division of Insurance's 2000 annual report describes Chapter 141 as a broad managed care law that created the Bureau of Managed Care and the Office of Patient Protection, expanded and modified the prompt payment provisions that apply to insurance carriers, raised HMO licensure requirements, and added a new chapter of the General Laws, Chapter 176O, Health Insurance Consumer Protections, with carrier accreditation, internal and external grievance review and Division enforcement powers. The 45-day claim response rule a practice cites in A/R follow-up comes from that law, and the grievance route it created is where a member-side dispute goes.

• Primary Care ACO and PCC Plan claims are paid fee-for-service by MassHealth, not by a capitated plan³

  CMS's 2024 state tables list seven MassHealth delivery systems: the Primary Care Accountable Care Organizations (Community Care Cooperative and Steward Health Choice), the Primary Care Clinician Plan, the two managed care organizations (Tufts Health Together and WellSense Essential MCO), 15 Accountable Care Partnership Plans, a behavioral health prepaid inpatient health plan run by the Massachusetts Behavioral Health Partnership, the Senior Care Options plans and the PACE organizations. For Primary Care ACO and PCC Plan enrollees, services other than behavioral health, and for the Primary Care ACOs certain primary care services, are paid by MassHealth through fee-for-service directly to providers and not through capitation, with behavioral health provided by the Massachusetts Behavioral Health Partnership. The MCOs and Accountable Care Partnership Plans run statewide under the 1115(a) demonstration, cover nursing facility, chronic or rehabilitation hospital care up to 100 days per contract year per enrollee, and leave long-term services and supports in fee-for-service. New enrollees in those plans and in the Primary Care ACOs get 14 days to choose and a 90-day plan selection period, repeated for 90 days each year, so the plan on file can change within the first three months.

Services for Massachusetts practices

Remitwright serves Massachusetts practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits