C O M M O N W E A LT H O F M A S S A C H U S E T T S E X E C U T I V E O F F I C E O F H E A LT H A N D H U M A N S E R V I C E SMassHealth Nonbilling Provider Contract for Individuals This Nonbilling.
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How to fill out the MassHealth Nonbilling Provider Contract for Individuals online
This guide provides a clear and comprehensive overview of how to correctly fill out the MassHealth Nonbilling Provider Contract for Individuals online. It is designed to assist users of all backgrounds, ensuring a smooth and efficient application process.
Follow the steps to fill out the form accurately and efficiently.
- Press the ‘Get Form’ button to acquire the form and open it in your browser for editing.
- Begin with the 'Applicant Information' section. Input your legal name, date of birth, and social security number (SSN). If your SSN is pending, provide an explanation.
- Enter your National Provider Identifier (NPI) number and select your provider type from the listed options.
- Next, provide details about any applicable DEA number and select the relevant checkboxes based on your prescription status.
- Fill in your home address and contact information accurately. If your primary service location differs from your home address, ensure to complete that section as well.
- Complete the 'Section 2: Disclosures'. This section requires you to disclose any ownership interests or relationships as stipulated. If none, check the 'None' box.
- For any questions regarding criminal convictions or disciplinary actions, respond accurately and provide detailed explanations as needed.
- Sign and date the certification statement at the end of the application. Ensure that the signature is your own, as stamps or third-party signatures are not permitted.
- After completing the form, review all information for accuracy. Then, save your changes and prepare to submit it as per the outlined submission process.
Take the next step in your application process and fill out the MassHealth Nonbilling Provider Contract online today!
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How do I enroll in Mass Health provider?
MassHealth Provider Enrollment For enrollment or more information, go to the Provider Online Service Center or call the MassHealth Customer Service Center at (800) 841-2900. You may need to pay an application fee.
What is the division of medical assistance in Massachusetts?
The Division of Medical Assistance (DMA) is the single state agency in Massachusetts that administers Medicaid (Title XIX) and the State Children's Health Insurance Program (SCHIP) (Title XXI). In Massachusetts, Medicaid and CHIP are combined into one program called MassHealth.
Where do I send my MassHealth Nonbilling provider contract?
Please complete, sign, and return this form and the Nonbilling Provider Contract by mail to the MassHealth Customer Service Center (CSC), Attn. Provider Enrollment, P.O. Box 121205, Boston, MA 02112 – 1205.
What is the phone number for Massachusetts provider?
If you are currently a MassHealth provider but do not know your Username and password, please contact the Customer Service Center at 1-800-841-2900.
How do I contact MassHealth for providers?
A: You may contact the MassHealth LTSS Provider Service Center by phone at (844) 368-5184, or via e-mail at support@masshealthltss.com.
How do I contract with MassHealth?
MassHealth Provider Enrollment For enrollment or more information, go to the Provider Online Service Center or call the MassHealth Customer Service Center at (800) 841-2900. You may need to pay an application fee.
What is the income limit for MassHealth in Massachusetts?
2023 MassHealth Income Standards and Federal Poverty Guidelines Family SizeMassHealth Income Standards100% Federal Poverty LevelMonthlyYearly1$522$14,5802$650$19,7283$775$24,8646 more rows
How to apply to Mass Health as a non billing provider?
To enroll as a billing provider, contact MassHealth Customer Service Center at 1-800-841-2900 and request an application. To enroll as a non-billing provider, complete the application and contract at http://.mass.gov/eohhs/docs/masshealth/aca/pe-nbp-con.pdf. Keep a copy of the application for your records.
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