Get Timely Filing Waiver Form - Masspartnership

Filling out the Timely Filing Waiver Form for the Massachusetts Behavioral Health Partnership is a crucial step for providers seeking to request a waiver for late claim submissions. This guide provides clear and supportive instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the Timely Filing Waiver Form online.

1. Click ‘Get Form’ button to obtain the Timely Filing Waiver Form and open it in your preferred online editor.
2. Begin by entering the provider name in the designated field. Ensure that you provide the exact name as registered.
3. Input the enrollee name accurately to identify the individual for whom the waiver is being requested.
4. Fill in the provider number. This number is essential for verifying your credentials.
5. Enter the enrollee number, which helps to distinguish the enrollee's unique account.
6. Complete the provider address field to ensure that communications are sent to the correct location.
7. Specify the date of service accurately to reflect when the service was provided.
8. Enter the original claim number. This is necessary for tracking purposes.
9. Select whether the original claim was filed in a timely manner by checking 'Yes' or 'No'.
10. If 'No,' provide a brief explanation for the delay in the designated space.
11. Choose the reason for the waiver request from the provided options: retroactive enrollee eligibility, retroactive clinical authorization, or other. If selecting 'other,' provide a detailed explanation.
12. Review the form for completeness and accuracy, ensuring all fields are filled out to avoid delays.
13. Sign and date the form in the designated fields to authorize the request.
14. Finally, save your changes, and download or print the completed form as necessary for your records or submission.

Complete your Timely Filing Waiver Form online today for a smooth filing process.