Updated Claims Detections for Independent Nurses
July 8, 2024
On August 1, 2024, MassHealth will be implementing certain claims detections to prevent Independent Nurse (IN) claims from paying when the service hours are not billed in accordance with applicable MassHealth regulations, specifically 130 CMR 414.000: Independent Nurse. The claims edits will detect and suspend payment in the following circumstances:
- If an IN bills for overtime units using modifiers TU or U4 before they bill for 40 units of standard CSN services in a calendar week (starting Sunday 12 am and ending Saturday 11:59 pm).
- If an IN bills for greater than 20 hours of overtime units using modifiers TU or U4 in a calendar week (starting Sunday 12 am and ending Saturday 11:59 pm).
- If an IN bills for greater than 60 hours of CSN services (using any procedure code or modifier) in a calendar week (starting Sunday 12 am and ending Saturday 11:59 pm).
If you have questions, please contact the LTSS Provider Service Center at (844) 368-5184 or support@masshealthltss.com.