As you’re likely aware, MassHealth is implementing changes in early 2027 which will require managed care entities to submit encounter data through their Standardized Encounter Data Program (SENDPro), with more stringent enforcement of data quality standards. 

In anticipation of these changes, we are reminding our provider partners to include key data elements when submitting claims to Point32Health to ensure accurate claim adjudication, encounter submission, and timely reimbursement. 

MassHealth’s Managed Care Entity Bulletin 133 outlines changes that will substantially impact encounter data validations and highlights priority areas that will create challenges if not implemented correctly — some of which are identified below. 

  • Provider taxonomies: Providers should include valid and up-to-date taxonomy codes on all medical encounter submissions (all claim types except pharmacy). Refer to the latest National Uniform Claim Committee’s Health Care Provider Taxonomy Code Set for a list of valid taxonomies. Claims without appropriate taxonomy codes may be rejected. Include taxonomy codes for billing, attending, and rendering providers. 
  • National Provider Identifiers (NPIs): All claims must include a valid 10-digit NPI in the appropriate data element(s) for all provider types (e.g., billing, attending, referring, rendering and operating). Missing NPIs may result in claim rejection, except where atypical providers are not issued an NPI. 
  • Hospital admission date and time: Providers must include a valid admission hour and date on all applicable inpatient claims, with exceptions for certain bill types. Missing or invalid admission information may result in encounter validation failures. 
  • Hospital discharge hour: Include a valid discharge hour and date for all inpatient provider claims, with exceptions for certain bill types. 
  • Primary diagnosis codes: Use valid and active diagnosis codes appropriate for the date of service. Invalid or inactive primary diagnosis codes may be rejected. 
  • Occurrence codes: Use valid occurrence codes that accurately reflect the member's treatment and clinical history. 
  • Revenue codes: Submit only valid and reimbursable revenue codes. Verify revenue codes against current MassHealth guidance and fee schedules. 
  • National Drug Codes (NDCs): For physician-administered drugs, include a valid 11-digit NDC, appropriate unit of measure (F2, GE, ME, ML, or UN), and quantity greater than 0.0. 
  • Standardized codes: Providers must use standardized code sets (for procedure codes and modifiers, diagnosis codes, and any other standardized codes) and comply with all requirements for claims and encounter submissions. 

You can find more information on encounter data submission requirements in MassHealth’s various companion guides and related SENDPro communications.