EOHHS-MassHealth

Select all transaction type(s) which you are experiencing submission issues:

270 - Healthcare Eligibility Inquiry

276 - Health Care Claim Status Request

837 - Healthcare Claim Submission: Institutional or Professional

999/TA1 - Acknowledgement Transaction

Enter date the transaction was submitted:

Did you receive a 999 acknowledgment??

Yes

Provide a detailed explanation of the problems you are facing when submitting the transaction file(s)

Enter the provider information below:

DBA (“Doing Business As”) address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MassHealth PID/SL (“Provider ID/Service Location)

PID/SL consists of 10 characters: a 9-digit base number followed by an alphabetic service location letter (e.g., 123456789A)

Name

First Last

Phone

Submitter User Name