Massachusetts Medicaid: Updated guidance for MassHealth encounter data requirements
AI Summary
Starting early 2026, MassHealth will require more stringent claims review through its SENDPro system. All medical claims must include complete taxonomy codes, NPIs, admit/discharge dates for inpatient claims, valid primary diagnosis codes, occurrence codes, revenue codes, and NDC data for physician-administered drugs to avoid rejections.
Action Required
Immediately: Billing team must update all MassHealth claim submissions to include: 1) Taxonomy codes for all attending, rendering and billing providers, 2) 10-digit NPIs for all provider types (billing, attending, referring, rendering, operating), 3) Valid admission hour/date on inpatient claims per bill type requirements, 4) Standardized primary diagnosis codes (avoid codes like F02.80), 5) Valid occurrence codes matching member health conditions, 6) Valid revenue codes from MassHealth fee schedule (stop using revenue code 779), 7) Complete 11-digit NDC data with valid unit of measure and quantity >0.0 for physician-administered drugs. Update billing software validation rules and staff training materials. Claims missing these elements will be rejected starting early 2026.
Affected Billing Codes
Plan Types
Medicaid
States
MA
Specialties
all-specialties