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MassHealth SENDPro encounter data requirements
Effective date
Jan 1, 2027
Identified
Aug 16, 2026
Summary
MassHealth is implementing stricter encounter data requirements through SENDPro in early 2027, requiring providers to submit claims with complete and valid data elements including provider taxonomies, NPIs, admission/discharge times, diagnosis codes, occurrence codes, revenue codes, and NDCs. Claims missing or containing invalid data will be rejected, affecting claim adjudication, encounter submission, and reimbursement.
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What to do
Action · 12 steps
01Before January 1, 2027: Billing team and providers must implement comprehensive data validation procedures for all MassHealth claims submitted to Point32Health.
02Audit all claim submission workflows to ensure valid, up-to-date provider taxonomy codes (from NUCC Health Care Provider Taxonomy Code Set) are included for billing, attending, and rendering providers on ALL medical encounter submissions except pharmacy claims.
03Verify all claims contain valid 10-digit NPIs in appropriate data elements for billing, attending, referring, rendering, and operating providers, with exceptions only for atypical providers not issued NPIs.
04For inpatient hospital claims (with applicable exceptions for certain bill types), require valid admission date AND admission hour, and valid discharge date AND discharge hour.
05Implement validation rules to ensure only valid, active diagnosis codes appropriate for the date of service are submitted as primary diagnoses.
06Verify all occurrence codes accurately reflect member treatment and clinical history.
07Cross-reference all revenue codes against current MassHealth guidance and fee schedules to ensure only valid, reimbursable codes are submitted.
08For physician-administered drug claims, mandate valid 11-digit NDC, appropriate unit of measure (F2, GE, ME, ML, or UN), and quantity greater than 0.0.
09Ensure all procedure codes, modifiers, diagnosis codes, and other standardized codes comply with current code set requirements.
10WHO: Billing team (system configuration and validation setup), Providers (accurate data submission), and Compliance/Revenue Cycle leadership (oversight and monitoring).
11WHERE: Update billing system validation rules, claim submission templates, and encounter forms; configure system edits and hard stops to prevent submission of non-compliant data.
12CONSEQUENCES: Claims without appropriate taxonomy codes, missing NPIs, invalid admission/discharge information, inactive diagnosis codes, or non-compliant data will be rejected by Point32Health, resulting in claim denials, delayed encounter submission to MassHealth, and delayed or denied reimbursement.
Original notice
MassHealth SENDPro encounter data requirements
point32health.org · Always check the source before changing claims.