Working With Us

We’re an experienced, not-for-profit leader in Medicaid and committed to providing high quality health coverage to underserved populations. We’re making it easier for providers like you to work with us.

See if a Prior Authorization is Required

Before scheduling a service or procedure, determine whether or not it requires prior authorization.

  1. Search prior authorization requirements by using one of our lookup tools:
  2. If approval is required, review the medical and payment policies
  3. Reference your patient’s covered services list to understand what’s covered by their plan
  4. Download and submit the prior authorization form:

Appeals

If your prior authorization is denied, you or the member may request a member appeal. The Plan may be required to get written permission from the member for you to appeal on their behalf. For more information on the member appeal process, please reference the prior authorization denial letter or Section 10 of the Provider Manual: Appeals, Inquiries and Grievances.

Documents & Forms

Access prior authorization forms and documents.

Submit Claims 

Claims should be submitted within 90 days for Qualified Health Plans including ConnectorCare, and within 150 days for MassHealth and Senior Care Options. To expedite payments, we suggest you submit claims electronically through our online portal.

To submit paper claims by mail, enter claims data on the CMS-1500 form and send them to:

BMC HealthNet Plan
Claims Department
PO Box 55282
Boston, MA 02205-5282

Log in to the provider portal to check the status of a claim or to request a remittance report.

Non-Participating Providers: Please refer to the tab labeled "Non-Participating Providers".

 
More Claims Information

For earlier submissions and faster payments, claims should be submitted through our online portal or register with Trizetto Payer Solutions here. Or use the following clearinghouses:

  • Gateway EDI
  • NEHEN (New England Healthcare EDI Network)

You must correct claims that were filed with incorrect information, even if we paid the claim.

The most common reasons for rejected claims are:

  • The NPI is incorrect, not listed on the claim, or does not match the tax identification number in our system.
  • The member ID number is invalid.
  • The original claim number is not included (on a corrected, replacement, or void claim).

Please be aware that:

  • If we reject a claim for a missing NPI number, you must submit it as a new claim with updated information.
  • If we request additional information, you should resubmit the claim with the additional documentation. Do not submit it as a corrected claim.

Electronic Claims

The process for correcting an electronic claim depends on what needs to be corrected:

  • To correct the provider name, NPI number, member name, or member ID number, you must first process a void claim, and then file a new claim.
  • To correct billing errors, such as a procedure code or date of service, file a replacement claim.

Replacement and void claims must include the original claim number in a specific position in the 837: Loop 2300, Segment REF - Original Reference Number (ICN/CDN), with “F8 ” in position 01 (Reference Identification Qualifier) and the original claim number in position 02.

For more information on electronic placement and void requests, please see the EDI Claims Companion guide for 5010, or contact your Provider Relations representative.

Paper Claims

To submit a corrected paper claim:

  • Print out a new claim with corrected information.
  • Write "Corrected Claim" and the original claim number at the top of the claim.
  • Circle all corrected claim information. Please do not hand-write in a new diagnosis, procedure code, modifier, etc.
  • Include the Plan claim number, which can be found on the remittance advice.
  • Submit the claim in the time frame specified by the terms of your contract to:

    BMC HealthNet Plan
    P.O. Box 55282
    Boston, MA 02205

Returned Checks

If you received a check with the wrong pay-to information, send it back to us at the above address along with the correct provider pay-to information. Then we will reissue the check.

Refunding Overpayments

If you received an overpayment, complete this form to credit the money back to us. Please return the form within 60 days of receipt of the overpayment by mail or fax.

BMC HealthNet Plan
Credit Balance Department
529 Main Street, Suite 500
Boston MA, 02129
Fax: 617-897-0811

Submit a Provider Administrative Claims Appeal

If you don't agree with how a claim was processed, you can request a claim review using the Universal Request for Claim Review Form. Forms must be submitted with all required information, including but not limited to completion of all fields denoted with an asterisk (*) and the correct Review Type box. If using “Other” on the form, you must document specific information pertaining to your request. Incomplete forms will be returned to the submitting provider for completion and appeal resubmission. Submit the form, the required written narrative and supporting documentation within your contracted timely filing limit to the address below. We have a one-level appeals process and will make a determination within 30 days following receipt of the appeal accompanied by the appropriate documentation. A resolution letter describing the decision is mailed to you upon completion of our review.

Please access the Provider Administrative Claims Appeal Process policy found on our website for additional information regarding this process.

The following types of provider administrative claim appeals are IN SCOPE for this process:

  • Level of Compensation/Reimbursement
  • Timely Filing of Claims • Retroactive Eligibility
  • Lack of Prior Authorization/Inpatient Notification Denials
  • Non-Covered and/or Unlisted Code Denials
  • Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB)
  • Provider Audit and Special Investigation Unit (SIU) Appeals
  • Duplicate Claim Appeals

The following are considered Claim Issues and are OUT-OF-SCOPE for this process and must be sent to the appropriate departments:

  • Claim Adjustments
  • Corrected Claims
  • Claim Resubmissions
  • Claims Involving OPL/TPL/COB*

*Note: Claims issues involving OPL/TPL/COB are not necessarily appeals involving OPL/TPL/COB claims. Providers are responsible for sending their requests to the appropriate address via the required method(s).

Mail appeals and supporting documents to:

BMC HealthNet Plan 
ATTN: Provider Appeals 
P.O. Box 55282 
Boston, MA 02205

 

Documents & Forms

Access documents and forms for submitting claims and appeals.

Check Member Eligibility

Log in to our provider portal to check member eligibility. You can also check the status of claims or payments and download reports using the provider portal.

Non-Participating Providers 

If you are not a BMC HealthNet Plan network provider and will be administering a one-time service to a BMC HealthNet Plan member, you must do the following to receive payment:

Prior Authorization

You must receive prior authorization before delivering services to a BMC HealthNet Plan member. Complete the Universal Massachusetts Prior Authorization Form, or call 800-900-1451, Option 3.

If you do not obtain prior authorization, your claim may be denied, unless the claim is for emergency care. 

Senior Care Options

If you're delivering a service to a BMC HealthNet Plan Senior Care Options member, you must also submit a Waiver of Liability.

Documents & Forms

Access administrative forms and documents.

Geriatric Depression Resources

Our behavioral health partner, Beacon Health Strategies, developed a series of tools and resources for medical providers regarding geriatric depression.

Learn More

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