November 21, 2025
Massachusetts Medicaid: Updated guidance for MassHealth data requirements
Avoid claim rejections, denials and reimbursement delays
Starting in early 2026, MassHealth will require managed care entities (MCEs) to more stringently review claims for accuracy before submitting them through its Standardized Encounter Data Program (SENDPro).
Effective immediately, please review the following table and apply the updated guidelines before submitting claims to UnitedHealthcare. Staying in compliance will help ensure smooth claims processing and timely reimbursement.
MassHealth encounter data requirements
| Name | Definition | Issue | Action required |
|---|---|---|---|
| Taxonomy codes | Designates the classification and specialization of the providers. Associated with the provider’s NPI. | Claims without taxonomy codes will be rejected (except pharmacy claims). | Include relevant taxonomy code on all medical encounter submissions for all attending, rendering and billing providers. |
| National Provider Identifier | Accurately maps the provider’s identification and service location, helping to ensure adequate taxonomy coverage in network areas. | Claims missing NPI for provider types will be rejected (except atypical providers not issued an NPI). | Include 10-digit NPI for all provider types: billing, attending, referring, rendering and operating. |
| Admit/discharge dates/times | Identifies the number of days for a member’s stay. | Missing or invalid admission hour/date on inpatient claims (with exceptions for some bill types). | Review bill type requirements and include valid admission hour and date on applicable inpatient provider claims.* |
| Primary diagnosis codes | Identifies the reason for a member’s visit. MassHealth will be publishing a list of diagnosis codes that are allowed to be primary diagnosis codes. We’ll share the link when it’s available. | Claims with invalid or inactive diagnosis codes for primary diagnosis on the date of service will be rejected. For example, diagnosis code F02.80 is not permitted as a primary diagnosis. | Use standardized procedure codes and modifiers; ensure codes are valid and required fields populated. |
| Occurrence codes | Identifies details about the member’s treatment and history. | Invalid occurrence codes not matching member’s health condition will be rejected. | Use valid occurrence codes that align with member’s health condition. |
| Revenue codes | Identifies the type of service provided to members. | Invalid revenue codes are not reimbursable and will be rejected. Note: MassHealth flagged revenue code 779 as invalid and should not be billed. | Verify all revenue codes are listed on the MassHealth fee schedule before submitting claims. Avoid billing codes that are not reimbursable. |
| National Drug Code | Universal identifier of the drug’s manufacturer, product and package size. | Missing/invalid NDC data for physician-administered drugs. | Include 11-digit NDC, valid unit of measure (F2, GE, ME, ML, UN) and quantity (must be greater than 0.0). |
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* SENDPro added the following custom validations to require admit/discharge dates/times in 837I submissions:
- L2300DTP*435 (admit date) require when: CLM05-01in (11, 12, 18, 21, 22, 25, 26, 27, 28, 31, 32, 34, 41, 42, 46, 48, 61, 62, 64, 65, 66, 67, 68, 81, 82, 86).
- L2300DTP*096 (discharge hour) requires when CL103!=30 AND CLM05-01 in (11, 18, 25, 26, 27, 28, 41, 42, 46, 48, 61, 62, 64, 65, 66, 67, 68, 86).
PCA-1-25-02432-C&S-NN_11142025
