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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.
- Search prior authorization requirements by using one of our lookup tools:
- If approval is required, review the medical and payment policies
- Reference your patient’s covered services list to understand what’s covered by their plan
- Submit the prior authorization request:
- For Medical Prior Authorizations, submit electronically to BMC HealthNet Plan through our online portal
- For pharmacy prior authorizations, click here
*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant. The online portal is the preferred method for submitting Medical Prior Authorization requests. The Medical Prior Authorization Form can also be downloaded from the Documents & Forms Section, if necessary.
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. (submitting via the Provider Portal, MyHealthNet, is the preferred method)
Access training guides for the provider portal.
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 and encourage you to submit claims electronically. Providers can submit claims electronically directly to BMC HealthNet Plan through our online portal or via a third party. You can register with Trizetto Payer Solutions or, use the following clearinghouses:
- Gateway EDI
- NEHEN (New England Healthcare EDI Network)
Paper claims may be submitted via U.S. mail by filling out the CMS-1500 form and sending to the address below for covered services rendered to BMC HealthNet Plan members. Sending claims via certified mail does not expedite claim processing and may cause additional delay.
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MassHealth & QHP: BMC HealthNet Plan |
SCO only: BMC HealthNet Plan |
Non-Participating Providers: Please refer to the tab labeled "Non-Participating Providers".
*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.
Log in to the provider portal to check the status of a claim or to request a remittance report.
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, please return it to us to the address below along with the correct provider Pay-To information. We will then, reissue the check.
Refunding Overpayments
Common overpayment reasons include payments for services for which another payer is primary, incorrect billing, and claim processing errors such as duplicate payments. Providers are required to perform due diligence to identify and refund overpayments to BMC HealthNet Plan within 60 days of receipt of the overpayment.
Providers should not submit refund checks for credit balance payments; instead, please contact us using one of the methods below and we will adjust your claim(s) and recover the credit balances through future payment offsets.
- The preferred method is to submit the Credit Balance request through our online portal. See instructions in the Request for Claim Review Section.
- Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Fax: 617-897-0811
- Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Email (please send securely by encrypting the email)
- Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Mail:
BMC HealthNet Plan
Credit Balance Department
529 Main Street, Suite 500
Boston MA, 02129
Fax: 617-897-0811
*If you require training or assistance with our online portal, please contact your dedicated Provider Relations Consultant.
Providers can update claims, as well as, request administrative claim appeals electronically through our online portal.
The following review types can be submitted electronically:
- Contract terms: provider is questioning the applied contracted rate on a processed claim.
- Coordination of Benefits (COB): for submitting a primary EOB.
- Corrected Claim: when a change is being made to a previously processed claim. Identify the changes being made by selecting the appropriate option in the drop down menu.
- Duplicate Claim: when submitting proof of non-duplicate services.
- Filing Limit: when submitting proof of on time claim submission.
- Payer Policy, Clinical: when the provider is questioning the applied clinical policy on a processed claim.
- Pre Auth: when submitting proof of authorized services.
- Request for Additional Information: when submitting medical records, invoices, or other supportive documentation.
- Retraction of Payment: when requesting an entire payment be retracted or to remove service line data.
Once you complete and submit the online Request for Claim Review, you will receive a confirmation screen to confirm that your request was submitted successfully. For further instruction, review the Update Claims Reference Guide located in Documents and Forms.
*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.
Submit a Provider Administrative Claims Appeal
Providers may request that we review a claim that was denied for an administrative reason. We offer one level of internal administrative review to providers. The administrative appeal process is only applicable to claims that have already been processed and denied. An administrative appeal cannot be requested for services rendered to a member who was not eligible on the date(s) of service, or for benefits that are not administered or covered by BMC HealthNet Plan. Submit the administrative appeal request within the time frames specified in the Provider Manual.
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
All documentation a provider wishes to have considered for a provider administrative appeal must be submitted at the time the appeal is filed. Once a decision has been reached, additional information will not be accepted by BMC HealthNet Plan. Providers can submit an Administrative Claim Appeal electronically via our secure provider portal, or via US Mail:
- The preferred method is to submit the Administrative Claim Appeal request through our online portal. See instructions in the Request for Claim Review Section.
- Download and complete the Request for Claim Review Form and submit with all required documents via Mail. Sending requests via certified mail does not expedite processing and may cause additional delay.
BMC HealthNet Plan
Attn: Provider Administrative Claims Appeals
P.O. Box 55282
Boston, MA 02205
*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.
Documents & Forms
Access documents and forms for submitting claims and appeals.
Access training guides for the provider portal.
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
Notice: Federal No Surprises Act Qualified Services/Items
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:
- Complete the Non-Participating Provider Activation Form
- Fax the completed form, along with a copy of your W-9 form, to 617-897-0818, to the attention of the Provider Enrollment Department
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.