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  • 90-day Waiver Request Form 90-dwr - Mass.gov - Mass

Get 90-day Waiver Request Form 90-dwr - Mass.gov - Mass

Acy and dental, please complete this form for every claim and attach applicable supporting documentation to each one. Effective April 1, 2013, 90-day waivers must be submitted electronically unless the provider has an approved electronic claims submission waiver. Ninety-day waiver requests must be submitted electronically via direct data entry (DDE) using delay reason code 1, 4, or 8. Date of Request: Provider Name: Provider Address: MassHealth Provider ID/Service Location: Reason for Request Yo.

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Only providers who have received an approved electronic waiver may submit paper claims.

To file an appeal by telephone, you may call the MassHealth Customer Service Center at (800) 841-2900, TDD/TTY: 711. Self-service is available 24 hours per day in English and Spanish. Other services are available Monday through Friday, 8 a.m.– 5 p.m. Interpreter service is available.

Please send your 90-day waiver requests to the following address: MassHealth Attn: 90-Day Waiver Unit P.O. Box 9118 Hingham, MA 02043 Copies of the 90-day waiver request form can be downloaded from .mass.gov/masshealth. Click on MassHealth Provider Forms on the lower right side of the page.

You must file the appeal within 30 days of the date that appears on the remittance advice on which your claim first denied with error code 853 or 855.

90 Days Initial claims must be received by MassHealth within 90 days of the service date. If you had to bill another insurance carrier before billing MassHealth, you have 90 days from the date of the explanation of benefits (EOB) of the primary insurer to submit your claim.

If you have questions about medical claims, billed by Doctors, Nurse Practitioners, Pharmacies, and Hospitals, contact MassHealth Customer Service at (800) 841-2900, Monday through Friday from 8:00 a.m.–5:00 p.m., excluding holidays, or by email to providersupport@mahealth.net.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232