Submit Claims

Claims should be submitted within 90 days for Qualified Health Plans including ConnectorCare, and within 150 days for MassHealth and Senior Care Options.

To expedite payments, we suggest and encourage you to submit claims electronically. Providers can submit claims electronically directly to WellSense through our online portal  or via a third party. You can register with Trizetto Payer Solutions or, use the following clearinghouses:

  • Gateway EDI
  • NEHEN (New England Healthcare EDI Network)

Paper claims may be submitted via U.S. mail by filling out the CMS-1500 form and sending to the address below for covered services rendered to WellSense members. Sending claims via certified mail does not expedite claim processing and may cause additional delay.

MassHealth & QHP:
WellSense Health Plan
P.O. Box 55282
Boston, MA 02205-5282

SCO only:
WellSense Health Plan
P.O. Box 55991
Boston, MA 02205-5049

Non-Participating Providers: Please refer to the tab labeled "Non-Participating Providers".

*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.

Log in to the provider portal to check the status of a claim or to request a remittance report.

More Claims Information

For earlier submissions and faster payments, claims should be submitted through our online portal or register with Trizetto Payer Solutions here. Or use the following clearinghouses:

  • Gateway EDI
  • NEHEN (New England Healthcare EDI Network)

You must correct claims that were filed with incorrect information, even if we paid the claim.
The most common reasons for rejected claims are:

  • The NPI is incorrect, not listed on the claim, or does not match the tax identification number in our system.
  • The member ID number is invalid.
  • The original claim number is not included (on a corrected, replacement, or void claim).

Please be aware that:

  • If we reject a claim for a missing NPI number, you must submit it as a new claim with updated information.
  • If we request additional information, you should resubmit the claim with the additional documentation. Do not submit it as a corrected claim.

Electronic Claims

The process for correcting an electronic claim depends on what needs to be corrected:

  • To correct the provider name, NPI number, member name, or member ID number, you must first process a void claim, and then file a new claim.
  • To correct billing errors, such as a procedure code or date of service, file a replacement claim.

Replacement and void claims must include the original claim number in a specific position in the 837: Loop 2300, Segment REF - Original Reference Number (ICN/CDN), with “F8 ” in position 01 (Reference Identification Qualifier) and the original claim number in position 02.

For more information on electronic placement and void requests, please see the EDI Claims Companion guide for 5010, or contact your Provider Relations representative.

Paper Claims

To submit a corrected paper claim:

  • Print out a new claim with corrected information.
  • Write "Corrected Claim" and the original claim number at the top of the claim.
  • Circle all corrected claim information. Please do not hand-write in a new diagnosis, procedure code, modifier, etc.
  • Include the Plan claim number, which can be found on the remittance advice.
  • Submit the claim in the time frame specified by the terms of your contract to:
    WellSense
    P.O. Box 55282
    Boston, MA 02205

Returned Checks

If you received a check with the wrong Pay-To information, please return it to us to the address below along with the correct provider Pay-To information. We will then, reissue the check.

Refunding Overpayments

Common overpayment reasons include payments for services for which another payer is primary, incorrect billing, and claim processing errors such as duplicate payments. Providers are required to perform due diligence to identify and refund overpayments to WellSense within 60 days of receipt of the overpayment.

Providers should not submit refund checks for credit balance payments; instead, please contact us using one of the methods below and we will adjust your claim(s) and recover the credit balances through future payment offsets.

  • The preferred method is to submit the Credit Balance request through our online portal. See instructions in the Request for Claim Review Section.
  • Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Fax: 617-897-0811
  • Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via email (please send securely by encrypting the email)
  • Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Mail:
    WellSense
    Credit Balance Department
    529 Main Street, Suite 500
    Boston MA, 02129
    Fax: 617-897-0811

*If you require training or assistance with our online portal, please contact your dedicated Provider Relations Consultant.

Providers can update claims, as well as, request administrative claim appeals electronically through our online portal.

The following review types can be submitted electronically:

  • Contract terms: provider is questioning the applied contracted rate on a processed claim.
  • Coordination of Benefits (COB): for submitting a primary EOB.
  • Corrected Claim: when a change is being made to a previously processed claim. Identify the changes being made by selecting the appropriate option in the drop down menu.
  • Duplicate Claim: when submitting proof of non-duplicate services.
  • Filing Limit: when submitting proof of on time claim submission.
  • Payer Policy, Clinical: when the provider is questioning the applied clinical policy on a processed claim.
  • Pre Auth: when submitting proof of authorized services.
  • Request for Additional Information: when submitting medical records, invoices, or other supportive documentation.
  • Retraction of Payment: when requesting an entire payment be retracted or to remove service line data.
Once you complete and submit the online Request for Claim Review, you will receive a confirmation screen to confirm that your request was submitted successfully. For further instruction, review the Update Claims Reference Guide located in Documents and Forms.

*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.

Submit a Provider Administrative Claims Appeal

Providers may request that we review a claim that was denied for an administrative reason. We offer one level of internal administrative review to providers. The administrative appeal process is only applicable to claims that have already been processed and denied. An administrative appeal cannot be requested for services rendered to a member who was not eligible on the date(s) of service, or for benefits that are not administered or covered by WellSense. Submit the administrative appeal request within the time frames specified in the Provider Manual.

The following types of provider administrative claim appeals are IN SCOPE for this process:

  • Level of Compensation/Reimbursement
  • Timely Filing of Claims
  • Retroactive Eligibility
  • Lack of Prior Authorization/Inpatient Notification Denials
  • Non-Covered and/or Unlisted Code Denials
  • Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB)
  • Provider Audit and Special Investigation Unit (SIU) Appeals
  • Duplicate Claim Appeals

All documentation a provider wishes to have considered for a provider administrative appeal must be submitted at the time the appeal is filed. Once a decision has been reached, additional information will not be accepted by WellSense. Providers can submit an Administrative Claim Appeal electronically via our secure provider portal, or via US Mail:

  • The preferred method is to submit the Administrative Claim Appeal request through our online portal. See instructions in the Request for Claim Review Section.
  • Download and complete the Request for Claim Review Form and submit with all required documents via Mail. Sending requests via certified mail does not expedite processing and may cause additional delay.
    WellSense
    Attn: Provider Administrative Claims Appeals
    P.O. Box 55282
    Boston, MA 02205

*If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.

Documents & Forms

Access documents and forms for submitting claims and appeals.

Access training guides for the provider portal.