To submit a 90-day waiver request for claims other than pharmacy and dental, please complete this form for every claim and
attach applicable supporting documentation to each one.
Ninety-day waiver requests must be submitted electronically unless the provider has an approved electronic claims submission
waiver. The requests must be submitted electronically via direct data entry (DDE) using delay reason code 1, 4, or 8.
Date of Request
Provider Name
Provider Address
MassHealth Provider ID/Service Location
Reason for Request
You may request a 90-day waiver when one or more of the following conditions apply and the claim is not currently in a pend,
suspend, or paid status. Please check one or more of the applicable reasons and provide necessary documentation with
every claim.
The member or provider was retroactively enrolled with MassHealth. Use delay reason code 8 for member or 4 for
provider.
The member did not inform the provider of the member’s enrollment with MassHealth within 90 days of the date of
service. Use delay reason code 1.
The provider is making a change to a procedure or revenue code on a claim that was originally submitted on paper
within the time limits. Use delay reason code 8.
The provider is making a change to the member’s MassHealth ID number on a claim that was originally submitted
within the time limits defined in MassHealth regulations at 130 CMR 450.309 and 450.313. Use delay reason code 8.
The provider is making a change to the pay-to-provider number on a claim that was originally submitted within the
time limits defined in MassHealth regulations at 130 CMR 450.309 and 450.313. Use delay reason code 8.
Other. Use delay reason code 8. Please explain below.
Please consult the directory in Appendix A of your MassHealth provider manual for information on submitting 90-day waiver
requests in paper format.
To download this form, go to the Provider Library at www.mass.gov/how-to/submit-a-90-day-claim-waiver-request-
form. For additional information on how to submit a 90-day waiver request, refer to Subchapter 5, Part 6, in your MassHealth
provider manual.
Note: For pharmacy claims, download the 90-day waiver request form from www.mass.gov/masshealth/pharmacy. Click on
MassHealth Pharmacy Publications and Notices for Pharmacy Providers, and then, under Billing Forms, click on 90-Day Waiver Request
Form.
90-DWR (Rev. 03/18)
90-Day Waiver Request
THE COMMONWEALTH OF MASSACHUSETTS
Executive Office of Health and Human Services
