MassHealth Referrals

March 20, 2017

Starting next week we need to make sure that MassHealth patients enrolled in managed care plans and have referrals are being billed with the PCP as the Referring MD provider.

In the past as long as the referral number is attached, they’ve processed. Now we Also need to make sure the PCP is accurate and used as the Referring MD (We’ve also used the Group name PCP in the past). It will take a little bit of work to make sure all is updated. We should probably ask offices to report PCP along with Referral data so we can bring everything into alignment and slow denials.

SUBJECT: ALL PROVIDER BULLETIN 265: CHANGES TO PCC PROVIDER ONLINE SERVICE CENTER REFERRALS PROCESS MassHealth’s All Provider Bulletin 265, posted on Friday, March 3rd, outlines changes to the Primary Care Clinician (PCC) Provider Online Service Center (POSC) Referrals Process Section 6401(b) of the Affordable Care Act includes requirements related to ordering, referring, and prescribing (ORP) providers. If MassHealth requires a service to be ordered, referred, or prescribed, then ACA Section 6401(b) requires that

The billing provider include the ORP providers national provider identifier (NPI) on the claim; and 2. The ORP provider be enrolled with MassHealth as a fully participating individual provider or as a non-billing individual provider. Under these ordering, referring and prescribing requirements, claims for any service requiring a PCC referral must include the NPI of the individual referring provider in the referral loop of the electronic claim. The PCC entity/service location is listed as the referring provider on a PCC referral. As of March 27, 2017, CHCs, HLHCs, OPDs and group practices must now choose an individual MassHealth-participating physician or nurse practitioner on-staff at the PCC entity/service location as the individual referring provider when making a PCC referral. This will meet the ordering, referring and prescribing requirements which require the NPI of an individual referring practitioner to be on a claim submitted for the service referred by the PCC. The POSC referral information panel has been updated so that a CHC, HLHC, OPD or group practice PCC entity/service location must choose an on-staff individual physician or nurse practitioner at the service location of the PCC entity.

All Provider Bulletin 265 is available to download from the MassHealth web site. Go to and select “Provider Library” from the left panel. Click on “Provider Bulletins”. Then click on 2017 Bulletins . Then click on the bulletin to download. If you have any questions, please contact MassHealth customer services at 1-800-841-2900