MassHealth EVSpc 5.00 User Guide March 2012 About This Guide EVSpc is the Windows-based access method for the MassHealth Eligibility Verification System (EVS) to make it available as part of MassHealth’s Medicaid Management Information System (MMIS). The software enables you to receive eligibility information for MassHealth members using a personal computer (PC). You can save members’ information, send eligibility inquiries in batches, and store eligibility inquiries for your records. You can also review the status of adjudicated claims. This user guide describes in detail the features of EVSpc software, and includes the following main sections. * EVSpc Welcome screen – Describes the menu options available from this screen and tasks users can perform from here. * Data Setup – Describes the tasks users need to perform to set up data in the database to begin the eligibility verification procedure. * Eligibility Verification – Describes the steps involved in the eligibility verification process in detail. * Back-up/Restore Procedures – Describes the steps involved in the back-up/restore process in detail. * Contact Information – Provides MassHealth contact information for questions users may have about EVSpc. Table of Contents Introduction 1 Logging into EVSpc 2 Security Authentication Errors 5 EVSpc Welcome Screen 6 Data Setup 8 Batch Key Maintenance 8 Adding Batch Keys 9 Accessing Batch Key Information 9 Editing Batch Key Information 9 Deleting Batch Key Information 10 Member Information 10 Adding Member Information 10 Adding Member Information Using the Member Demographics List Screen 11 Using Batch Keys While Adding Member Information 12 Searching for Member Information 13 Editing Member Information 14 Deleting Member Information 14 Purging Member Information 14 Provider Information 14 Adding Provider Information 15 Editing Provider Information 15 Deleting Provider Information 15 Eligibility Verification 16 Single Eligibility Verification 16 Field Descriptions 17 Batch Eligibility Verification 18 Batch Eligibility Inquiry by Member ID 18 Batch Eligibility Inquiry by Name, Date of Birth, and Gender 18 Batch Eligibility Inquiry by Member Demographics 19 Submitting/Transmitting Batches for Eligibility Verification 20 Transmitting Batches Using EVSpc 20 Transmitting Batches Using EVScall 21 Creating the 270 File 21 Finding EVScall 22 Transmitting the 270 File 22 Receiving the 271 File 22 Inquiry History 23 Response Codes 25 View/Print Responses 26 Eligibility Reports 34 Claim Status 34 Claim Status Inquiry 34 Field Descriptions 36 Claim Status Response 37 Field Descriptions 39 Back Up/Restore Data Files 40 Member Information Table 40 Backup 40 Restore 41 Backing Up Other Information 41 Import/Export Data Files 41 Export 42 Import 42 Import/Export Other Information 42 Contact Information 43 Introduction The EVSpc software is a tool that enables providers to verify MassHealth member eligibility, primary care clinician (PCC), managed care, long-term care, behavioral health, and third-party-liability information. It is a Windows-based access method. The software has an additional functionality for checking the status of a claim submitted to MassHealth. It also provides documentation of this information that you may print out for a specified date. For providers who want to send batches of eligibility verification inquiries using HIPAA 270 transactions to EVS, but do not want to use the EVSpc interface, a pass-through program named EVScall (EVScall.exe) has been developed. This program is part of the installation package, offering a solution for large providers who wish to verify eligibility or to check the status of claims electronically within the context of their own existing system. For more information on incorporating EVScall into your provider system, please call MassHealth Customer Service at 1-800-841-2900. The software allows the provider to submit eligibility inquiries 24 hours a day, seven days a week. You can run the software on a single PC or, if you are at a large facility, you can install it on several computer workstations and access the same data source. When updates occur, you will be notified about how to obtain the update via the EVS Web site (www.mass.gov/masshealth/providerservicecenter) or by mail. Due to the sensitive nature of MassHealth members’ eligibility information, the provider must have a signed Trading Partner Agreement (TPA) on file and a valid user ID and password before activating the software. The user must also have the appropriate security permissions assigned to the User ID, on the Provider Online Service Center (POSC) to successfully submit and receive responses through EVSpc. The appropriate security permissions are: * eligibility verification; * claims status request; * submit/receive HIPAA requests (batch upload/download). If you do not have these permissions assigned to your user ID, please see your facility’s security administrator who coordinates access to the Provider Online Service Center (POSC) for your organization. Once assigned, this user ID is valid for all EVS access methods like POSC, EVSpc, and AVR. A provider is not required to sign a second TPA to use EVSpc. Logging into EVSpc You will not be able to perform any eligibility, claim status, or security functions until you have logged into EVSpc. Note: Make sure you have your EVSpc equipment number key handy. It is required to run the EVSpc software. The equipment number key is the same key as the one that was entered during the installation time. You will not be able to run EVSpc software if the equipment number key is invalid. To log into EVSpc you need a user ID and password. User ID and Password Specifications User ID User ID must be alphanumeric (letters and numbers only). It is case sensitive. It must be a minimum of three characters, with a maximum of 16 characters. Password Password must be a minimum of eight characters, with a maximum of 16 characters. It is case sensitive. The only special characters allowed (but not required) are :, !, @, #, $, and %. The password expiration policy is 90 days. When password has expired, you must login to Virtual Gateway Business Services to change your password. The EVSpc and EVScall login process has been enhanced to check the validity of the user’s password. Upon validation of the user ID and password, a new message will be triggered when the user’s password has 15 days or less expiration date from the calendar date. When the user’s password is expired, meaning the number days left for password expiration is zero days; the user cannot continue to use software until the password has been successfully changed via the Virtual Gateway Web Portal. Some of the password validation messages are shown below. An Invalid Login message will display when either user ID or password entered is invalid. A Password Reminder message will display when user’s password is due to expire in 15 days or less. A Password Reminder message will display when user’s password has expired. Security Authentication Errors Below is a list of possible security authentication errors when your transaction request is not successful, followed by explanations on how to resolve the problem. * Client transaction is not authorized/allowed. Check with your provider security administrator to ensure your ID is authorized with Upload/Download security roles. * Client authentication failed for user. Verify if the user ID and password you entered are valid. Also verify that your password has not expired. * User name is not authorized for servicing provider. Your user ID is not authorized to perform transactions against the servicing provider. * Security information setup error. No associated clerk ID to user name. Check with your provider security administrator. * Authentication failed for user ID: ERROR_RESOURCE_NOT_AVAILABLE. Verify that the user ID and password you entered are valid. For any questions about your user ID or password, contact MassHealth Customer Service at 1-800-841-2900. EVSpc Welcome Screen After you log in, the first screen you will see is the EVSpc Welcome screen. This screen provides you with the Main Menu for easy navigation. The following options are available on the Main Menu. Option Allows you to File Open options/exit from the application Tools Update/back up database Help Open the EVSpc help file Member Information Store member information for submission and submit batches Batch Inquires By Name Store member demographic information for submitting name inquiries in batches Inquiry History View past inquiries of members View/Print Last Response View or print one or more latest inquiries Single Eligibility Verification Verify one member at a time Check Claim Status Check the status of a processed claim electronically Provider Information Add, edit, or delete provider name, provider number, and/or provider NPI number information Batch Key Maintenance Maintain batch keys Exit Exit from the application Note: Options on the menu may change depending on where you are currently in the application. Data Setup Before using the EVSpc software, you must set up data that is required for performing tasks. You must set up the Batch Key table, and add the member and provider information in their respective tables. Batch Key Maintenance You must set up the Batch Key table before adding any member information to the database. Values in this table are used when adding members. The batch keys allow you to classify members, or a group of members into simple categories. This helps you perform inquiries on a group or subset of members in the Member Information table. For example, keys can be set up to identify members by doctor name, day of visit, patient account number, clinic, etc. Grouping members by batch keys is discussed in the section titled Using Batch Keys While Adding Member Information. Adding Batch Keys To add information to the Batch Key table, do the following. 1. Select the Add menu option. 2. Enter the batch key name in the Batch Key field. 3. Enter the description in the Key Description field. 4. Click Add. The information is saved. Note: Examples of information to be added include multiple doctors in a large practice, active or inactive, multiple provider sites, days of the week, or internal patient account numbers. Accessing Batch Key Information To access batch key information, on the EVSpc Main Menu, click Batch Key Maintenance. Editing Batch Key Information To edit information in the Batch Key table, do the following. 1. Highlight the record that needs updating. 2. Select the Edit menu option. 3. Edit the information that needs to be changed. 4. Click Update. The new information is saved. Note: The Batch Key field is not accessible for editing. Only the key description field can be edited. To change the batch key, delete the batch key entry and add a new entry. Deleting Batch Key Information To delete a batch key record from the Batch Key table, do the following. 1. Highlight the key to be deleted. 2. Select the Delete menu option. The information is deleted. Note: The Batch Key and Key Description fields are not accessible for editing in the delete function. Only the entire entry can be deleted from the database. Click Cancel to cancel the operation. Member Information To minimize the amount of time taken to verify member eligibility, you can enter information for a group of members. To enter member information, click the Member Information menu. Search for specific members or view all members in the Member Information database. The Member Information List displays the member records based on your search criteria. Adding Member Information To add members, do the following. 1. Select the Add menu option. 2. Enter required information into the fields. 3. Click Add. The information is saved. Adding Member Information Using the Member Demographics List Screen You can add members to the Member Demographic List in two ways. Using the Add menu option To add member information using the Add menu option, do the following. 1. Select the Add menu option. The Member Demographics Detail screen is displayed with the default provider number/NPI that you have authority to verify eligibility for. The date of service defaults to the current date. 2. Enter the name, date of birth, gender, and patient account number (optional) information. 3. Click Add to save the information. The fields are cleared to allow you to enter the next member details. 4. After entering all information, click Save and Close to discontinue the add loop. All entries are added to the Member Demographics database. Importing Member Information To import records from a comma-separated file format, do the following. 1. Select File, then Import. 2. Select the file you would like to import into the Member Demographics List. To import a comma-separated file, make sure the file specification is as described below. Last Name,First Name,Date of Birth,Gender,Provider Number,Date of Service,Patient Account Number Examples of import records: 1. Brown,Tom,12/01/1940,Male,1234567890,05/10/2005,BrownTom1201 2. Doe,Jane,10/13/1990,Female,1234567890,04/25/2005,DoeJane1013 3. Doe,John,04/15/1980,Male,,,DoeJohn0415 4. TEST,C,01/10/1990,F,1234567890,06/22/2005 5. TEST,C,01/10/1990,F,,06/22/2005 6. TEST,C,01/10/1990,F,1234567890,,TestC Note: The date of birth and date of service must be entered using the MM/DD/YYYY format. Using Batch Keys While Adding Member Information Three fields–Batch Key One, Batch Key Two, and Batch Key Three–can be used to classify the members or groups of members into categories. The keys are not required, but are designed to give providers the capability of inquiring on subsets of the main member list. Here are some examples: Identify member by the patient account number. Key One: Blank Key Two: Blank Key Three: 44567 Identify member by doctor name, day of visit, and patient account number. Key One: Dr. Smith Key Two: Monday Key Three: 44567 Identify member by clinic, active or inactive, and patient account number. Key One: Boston Key Two: Active Key Three: 090931 Keys One and Two, if used, must be entered in the Batch Key table through the Batch Key Maintenance option. Any value that is entered for the key fields must match what is entered in the Batch Key table. Key Three does not have to match values entered in the Batch Key table, but the drop-down arrow may be used to look up values from the Batch Key table. By using the key fields, you may transmit varying sizes of batched members. Searching for Member Information To search for a group of members, do the following. 1. Select the Search menu option. The Find Members screen is displayed. 2. Enter the search criteria for the group of members you are searching for. 3. Click OK. Note: By using combinations of the date of service, provider number/NPI, and the three keys, you will be able to select a large variety of groups of members for inquiry. Editing Member Information To edit member information, do the following. 1. Highlight the record that needs updating. 2. Select the Edit menu option. You may also double-click on a member. The Member Information screen is displayed. 3. Edit the information that needs to be changed. 4. Click Update. The new information is saved. Or click Cancel to cancel the operation. Deleting Member Information To delete a member record, do the following. 1. Highlight the record to be deleted. 2. Select the Delete menu option. The Member Information screen is displayed. 3. Click Delete. The information is deleted. Or click Cancel to cancel the operation and go back to the Member list. Purging Member Information To delete all members displayed on the list (purge), do the following. 1. Select the Purge menu option. A confirmation message is displayed indicating that all members on the list will be removed from the database. 2. Select Yes to remove all members on the list from the database. Or click No to go back to the Member list. Note: If a user selects this option to delete members, all member information that has been manually entered will be deleted from the EVSpc database. There is no “undo” feature other than if the user has a backup of the database. This function does not need to be done as part of normal use of the software. Purging Inquiry History does, however, need to be done periodically. Provider Information You can maintain NPI, provider ID, and provider name within EVSpc. This information is needed to populate the drop-down box on the Eligibility and Claim Status Request screen where you can select NPI, provider ID, and provider name to populate eligibility or claim status transaction. If any of the provider information changes, you can locally update the provider information. If the provider table is populated, the Provider List screen displays the NPI, provider ID, and provider name. It displays a blank list if there is no data in the provider table. You can use the Add button to add new provider information to the provider table, and the Update and Delete buttons to perform maintenance on it. Adding Provider Information To add providers, do the following. 1. Select the Add menu option. 2. Enter required information into the fields. 3. Click Add. The information is saved. Or click Cancel to cancel the operation. Editing Provider Information To edit provider information, do the following. 1. Highlight the record that needs updating. 2. Select the Edit menu option. You may also double-click on a provider record. The Provider Detail Information screen is displayed. 3. Edit the information that needs to be changed. 4. Click Update. The new information is saved. Or click Cancel to cancel the operation. Deleting Provider Information To delete a provider record, do the following. 1. Highlight the record to be deleted. 2. Select the Delete menu option. The Provider Detail Information screen is displayed. 3. Click Delete. The information is deleted. Or click Cancel to cancel the operation and go back to the provider list. Note: The Provider Detail Information screen is displayed for all three tasks of adding, editing, and deleting tasks. But the Add button is replaced by the Update button for the edit task, and by the Delete button for the delete task. Eligibility Verification There are two ways you can verify eligibility of members using EVSpc. * Single Eligibility Verification * Batch Eligibility Verification Single Eligibility Verification From the Main Menu, select Single Eligibility Verification. The MassHealth Member Eligibility Check screen is displayed. Single eligibility verification facilitates an inquiry using a member’s ID or member’s SSN/agency ID or member name (last name, first name, gender, and DOB). After an entry is made in one field, the additional fields will remain locked until the field with information is cleared. For each data-entry screen completed, select the Send button and a transmission is made immediately to verify the member's eligibility. After the response information is viewed and/or printed, select the Clear button to clear all fields in the data-entry screen in preparation for another eligibility check. Field Descriptions Field Description MassHealth Provider Number/NPI Select your MassHealth provider number/NPI by using the drop-down list to access the provider number/NPI to which you are assigned. This field defaults to the provider number/NPI associated with the user ID currently logged into EVSpc. This is a required field. Member ID Enter the 12-digit member ID. Social Security Number (SSN) or Other Agency ID Enter the nine-digit social security number, or the other agency ID of the member. Member’s Demographic Details These fields are name, date of birth, and gender. You can enter up to the first 60 characters of the member’s last name, at least the first character or up to the first 35 characters of the first name, member’s date of birth, and/or member’s gender. From Date of Service Use the drop-down calendar to enter the from date of service for the member. The from date of service defaults to the current date. This date must be less than four years prior to the current date. This is a required field. Note: The gap between from date of service and to date of service cannot be greater than 31 calendar days. To Date of Service Use the drop-down calendar to enter the to date of service for the member. This date cannot be a future date. This is a required field. If the to date of service is not entered, it defaults to the from date of service. Note: The gap between from date of service and to date of service cannot be greater than 31 calendar days. Once the chosen fields are filled, the transaction is ready to be sent to MassHealth for verification. Click Send to begin verification. A small window is displayed, which shows the transmission’s progress. When verification is complete, the response screen is displayed with the member’s eligibility information. Batch Eligibility Verification EVSpc offers three methods of verifying eligibility of members in a batch. * Batch Eligibility Inquiry by Member ID * Batch Eligibility Inquiry by Name, Date of Birth, and Gender * Batch Eligibility Inquiry by Member Demographics Batch Eligibility Inquiry by Member ID The batch eligibility inquiry by member ID allows you to retrieve member information by entering only the member’s ID. For more information about the member information function and maintaining members by their member ID, please see the Member Information section. Batch Eligibility Inquiry by Name, Date of Birth, and Gender This option allows you to inquire on a group of members for whom you do not have MassHealth identification numbers using name, date of birth, and gender. This information is displayed in the Member Demographic List and Detail screens. To begin entering member information, click the Batch Inquiries by Name menu option. Batch Eligibility Inquiry by Member Demographics To perform batch inquiry by member demographics, select the Batch Inquiries by Name option from the Main Menu. The Member Demographics List screen is displayed. If you had previously saved a list of member demographics, the saved information is displayed on the list. Note: * To date of service and patient account number information are optional. * Eligibility inquiries cannot be performed using the patient account number. The patient account number field allows the provider to maintain this information for informational purposes only. If entered, this number is returned as part of the response in the Inquiry Response screen. * Choose to set the provider number and from date of service values using the Change All function available in the Member Demographics List. * The Help option gives you context-sensitive information about transmitting batches. All members who receive an “eligible” or “ineligible” response will be removed from the Member Demographics List. These members are automatically added to the Member Information table with the member ID, name, and date of birth found in EVS. Future eligibility inquiries for these members can now be performed using the Member Information Batch Transmit process as previously discussed. A text file named “MemberNamesWithRID.txt” is created in the EVSpc directory on your PC, which lists each member that was added to the Member Information table. If the patient account number was entered in the Member Demographics List during a transmission, the patient account number is also listed for this member. You will receive a confirmation message indicating the number of users being added to the Member Information table. If you choose to view these members, the information is displayed in a text editor and EVSpc will remain inactive until you close the text editor. Once the text editor is closed, EVSpc becomes active and displays the response. A sample of the contents of the text editor is shown below: INSTRUCTIONS: 1. To print this file, select File and then Print. 2. On the Print window, click on the "Print" button. To return to the Eligibility Response, select File and then Exit. Please note that this file is overwritten every time a batch name inquiry is sent. Print this for your records before sending the next batch of name inquiries. Inquiry Date: 06/17/2005 Inquiry Time: 02:06:21 PM SMITH, JOHN, 01/31/1991, M, 999988888 BROWN, TOM, 10/01/1990, M, 111112222, BROWNTOM1201 All other members will remain in the Member Demographics List and the Reason Code field indicates the reason they remain on the list. The Reason Codes Description field, displayed below the list, includes the various reason codes and their corresponding descriptions. Submitting/Transmitting Batches for Eligibility Verification The final step in the eligibility verification process is transmitting the selected batch of members to MassHealth, and receiving the response. There are two ways you can transmit batches for eligibility verification. * Using EVSpc * Using EVScall Transmitting Batches Using EVSpc To submit/transmit batches for eligibility verification using EVSpc, do the following. 1. Add, delete, or edit members in the Member database. 2. Select a batch of members to verify by searching for them. 3. Select the Change All menu option. The Member Information Detail screen is displayed with the member information. 4. Enter from date of service, and click Change All. This updates all the members in the selected group with the correct from date of service. To date of service defaults to from date of service if not entered. Note: The date of service must be changed after each batch transmission. The batch process resets the date of service to blank on all members that receive an “eligible” or “ineligible” response. Members who do not have date of service reset will receive an error response. 5. Select the Transmit menu option. A progress meter displays the member currently being processed, and the total number of members to be processed. For example, if you submit a batch of 200 members, the batch meter window displays “Processing 1 of 200,” then “Processing 2 of 200,” etc. 6. Receive eligibility information on the Response screen. 7. Click Print to print a report. Transmitting Batches Using EVScall EVScall is an alternate way to submit HIPAA-compliant 270/271 transactions to MassHealth without using the features available in EVSpc. This method allows you to send batch inquiries to MassHealth automatically. It uses the communication mechanism offered in EVSpc to communicate to the MMIS Web site. It does not store member information, or keep track of your inquiry history as EVSpc does. It simply sends inquiries to MassHealth and returns the associated responses immediately back to you. EVScall is an ideal tool for facilities that have the ability of generating a HIPAA-compliant 270 inquiry file and receive a HIPAA-compliant 271 response file. Creating the 270 File The 270 file you create must be renamed as “inquiry.snd.” You must create this file in a specific format. Each transaction that you select to transmit becomes a record in the “inquiry.snd” file. You must ensure that the first record in the “inquiry.snd” file contains the user ID and password with a slash (/) separating them. You can include only one member within each interchange (ISA/IEA) envelope, and each ISA/IEA envelope must be on its own line. For more information on creating a 270 file, refer to the MassHealth 270/271 Companion Guide at www.mass.gov/masshealth. The following is a sample of the “inquiry.snd” file, where the first record is the user ID and password separated by a slash (/). Note: If the “inquiry.snd” file is not in the specified format, EVScall displays a message box that contains a description of the error and the record number it occurred on. If you cannot determine what the error is from the message displayed, please call MassHealth Customer Service at 1-800-841-2900 between 8 A.M. and 5 P.M. weekdays. Finding EVScall The EVScall application is available in the EVSpc directory C:\Program Files\EVSpc, by default. If you chose to install EVSpc in another directory, then look for the EVSpc folder to find this application. Transmitting the 270 File Once you have created a valid 270 file, and wish to transmit it to MassHealth, do the following. 1. Place the “inquiry.snd” file you created in the EVSpc folder. 2. Double-click on the EVScall icon. Transmission begins. If your 270 file is valid, the Batch Process Progress dialog box is displayed. This dialog box displays “Processing response” and “Receiving response” until the transmission of the file is complete. Once the transmission is complete, the dialog box closes. Receiving the 271 File Once transmission is complete, there will be a new file in the EVSpc folder called “inquiry.rcv.” The file is the 271 response to the most recent batch transmitted. This file can be read by any software that is capable of reading 271 format files, or can be viewed in any text editor. To view the file, right-click on the “inquiry.rcv” file and select the Open With option. On the resulting window you can either select Notepad, or any other text editor that you may have installed on your computer. Note: The “inquiry.rcv” file is overwritten each time you use EVScall and a transmission is made. If you want to save the inquiry responses from your previous batch, move the “inquiry.rcv” file out of the EVSpc folder, or rename it and include a date in the file name to keep track of which batch response that file represents. If you have trouble creating a 270 file, or interpreting a 271 file refer to the MassHealth 270/271 Companion Guide, which can be found at www.mass.gov/masshealth. If you have any questions about EVScall call MassHealth Customer Service at 1-800-841-2900 from 8:00 A.M to 5:00 P.M. weekdays. Inquiry History Whenever member inquiries, single or batch, are sent to MassHealth, the results of the verifications are stored as inquiry history. This allows you to check the results of past inquiries on members. To access a member's records, select the Inquiry History menu option. This screen allows you to search and view records in the Inquiry History database. The Inquiry History screen provides menu options for various tasks. Menu Description Search To search for a history of eligibility verifications for a member, enter the member's ID or other criteria, and click OK to retrieve all the history for that particular member or group of members. Another option is to use the View All button to see all inquiries for every member. Clear This option clears the list of inquiry history records currently displayed in the Inquiry History screen so that another search can be performed. Select This option highlights all of the inquiry history records that are currently displayed in the inquiry history screen to prepare for viewing/printing. View To view records retrieved from the Inquiry History database, highlight the record(s) to be viewed and select the View menu option. The Shift and Control keys can be used with the mouse to select multiple records. The inquiry will be displayed in the Response screen. Please see the View/Print Responses section for more information. Delete This option allows you to remove a single member inquiry at a time. To delete records retrieved from the Inquiry History database, highlight the record to be removed and select the Delete menu option. The inquiry response will be displayed in the Response screen. The available options in the Response screen are Delete and Cancel. To remove the inquiry information from the Inquiry History database, click Delete. This will remove the member inquiry from the list permanently. To return to the inquiry list, click Cancel. (Table continued on next page) Menu Description Purge This option allows you to remove or purge the records listed in the Inquiry History screen. To purge records from the Inquiry History database, search for the history records and select the Purge menu option. A confirmation message is displayed to confirm the purging of the Inquiry History records – “Select Yes to purge the information from the database or select No to cancel the purge.” It is recommended that you move the inquiry history records to an extended database before purging, if your organization requires you to maintain a permanent record of the responses. Response Codes The following is a list of response codes and their corresponding messages from the eligibility verification inquiry. Response codes are available on the Inquiry History screen. Code Message Displayed 1 Eligible 6 Ineligible 42 Unable to respond at current time 43 Invalid/missing NPI or provider identification 51 NPI or provider not on file 56 Inappropriate date 57 Invalid/missing date(s) of service 58 Invalid/missing date of birth 62 Date of service not within allowable inquiry period 63 Date of service in future 64 Invalid/missing member ID 67 Member not found 68 Duplicate member ID View/Print Responses After the eligibility inquiry has been checked, the response to the inquiry displays pertinent information about the member’s MassHealth status. The Inquiry Response screen displays the MassHealth member’s information, along with status and coverage type for the date of service verified. Additional information includes managed care, third- party-liability, primary care clinician, long-term care, behavioral health information, restrictive messages, and local office information. This screen also displays the responses received from previous inquiries by selecting the View option from the Inquiry History List. When viewing a response, selected information that is different from the prior response for the same member is highlighted in red. When you double-click the data field, the previous value of the field is presented in a pop-up box. The pop-up box does not work with some data fields such as data displays in the frame set. Depending on the number of records being viewed, this option allows you to view the records by using the Next and Previous buttons at the bottom of the screen. Selecting a single record to view does not give you the option to view other records using the Next and Previous buttons. You can choose to print eligibility reports by clicking Print Preview. The Print Options screen is displayed, so that you can select the various options for printing the inquiry responses. The following are a few more samples of the Inquiry Response screen. Eligibility Response with TPL Screen Other Insurance Information Eligibility Response with PCC Information Eligibility Response with MCO Information Eligibility Response with Behavioral Health Information Eligibility Response with Long-Term-Care Information Eligibility Response with Member Payment Responsibility Information Eligibility Reports EVSpc allows you to print reports of your inquiries in several different formats. When you receive an eligibility response on the Response screen, you have the option to print. To print your inquiry responses, click Print. The Print options screen is displayed. From this screen, you can do any of the following. * View the name of the printer to which the report can be sent for printing. Change the pre-installed printer from which you wish to print. * Change the page orientation of the printout to either landscape or portrait. * Display one or multiple members per page. * Sort by any field (up to three) in ascending or descending order. Claim Status EVSpc provides access to MassHealth's Claim Status Inquiry and Response System. The claim status subsystem provides you with the status of any claim you have submitted for a given member. After the response information is received, you may print the claim information for your reference or records. Claim Status Inquiry Claim status inquiry allows you to make a request using the member's ID. If you know other information on the submitted claim such as the service code or internal control number (ICN), this information can be entered and will be used to help limit the amount of claim information returned on the response. Field Descriptions Field Description Claim Reference Identification Reference number assigned by the originator to identify the transaction within the originator’s business application system. MassHealth Provider Number/NPI Select your MassHealth provider number/NPI using the drop-down list to access the provider number/NPI to which you are assigned. This field defaults to the provider number/NPI associated with the user ID currently logged into EVSpc. This is a required field. Member ID Enter the 12-digit member ID. This is a required field. Member Last Name Enter up to the first 60 characters of the member’s last name. This is a required field. Member First Name Enter up to the first 35 characters of the member’s first name. This is a required field. Member Middle Initial Enter one character for the member’s middle initial. Date of Birth Enter the member’s date of birth. This is a required field. Gender Select the member’s gender from the drop-down list. From Date of Service Use the drop-down calendar to enter the from date of service for the member. The from date of service defaults to the current date. This is a required field. Note: The gap between the from and to dates of service cannot be greater than six calendar months. To Date of Service Use the drop-down calendar to enter the to date of service for the member. This date cannot be a future date. This is a required field. If the to date of service is not entered, it defaults to the from date of service. Note: The gap between the from and to dates of service cannot be greater than six calendar months. ICN Enter the 13-digit ICN as shown on the remittance advice (RA). Inquire by ICN whenever possible. This will result in the quickest response to your request. Service Code Enter the code for the service that you billed on the claim. Patient Account Number Enter patient account number. This is a required field. Note: This entry will not be used as part of the search criteria, but must be entered. Original Billed Amount Enter original billed amount. This is a required field. Note: * You must be logged in with a valid user ID and password associated with the provider number under which the claim was submitted. * Due to the amount of information stored and what could be returned, it is suggested that you inquire by ICN whenever possible. This will result in the quickest response to your request. * Some information on the Claim Status Request screen that is required is not used in the search criteria, but is required to be present on the screen due to HIPAA regulations. As a result, it is recommended that fields such as the member’s date of birth, gender, and patient account number contain a default value that you continually enter for each claim status request. The system currently provides a default of “Unknown” for gender. * You can verify claims within six-month periods. This limitation has been placed on the system due to the large number of claims that could be returned on the response. Claim Status Response The claim status response is divided into sections. The top section is the claim detail information for the response, which displays the provider name, provider number/NPI, member ID, and member name (all based on the search criteria entered, not the search results). The patient account number, date of birth, and ICN are displayed in this section as well as charge amount, payment amount, status date, adjudication date, service date, check issue date, and claims status information. The second section is the list of services for a claim. This section summarizes an adjudicated claim that matches the search criteria used on the claim request. Key information for a claim will be displayed including detail, service code, units, charges, paid amount, and status. The user may click on Detail to immediately see the details associated with that specific service. The third section provides detailed information for each service detail. Click on Detail, under List of Services, to navigate through the service detail displays. When you highlight a particular detail, the Services Detail section becomes visible at the bottom of the screen. Field Descriptions Field Description Claim Detail Response Fields (Search Criteria Submitted) Claim Reference Identification Reference number assigned by the originator to identify the transaction within the originator’s business application system. Provider Provider name Provider ID Provider number/NPI Member ID Member’s 12-digit ID Patient Account # The provider’s internal tracking number for that MassHealth member Member Name Member’s full last name, full first name, and middle initial ICN Internal control number uniquely identifying a claim Charge Amount The charge amount submitted on the claim Payment Amount The amount paid on this claim by MassHealth Status Date The last date the status of the claim was updated Adjudication Date The date that the claim was adjudicated by MassHealth Service Date Date of service range submitted on the claim Check Issue Date The date that the claim check was issued by MassHealth Claim Status The last status update to this claim (paid, denied, pending, etc.). List of Services Detail A link to services detail record Service Code The service code for this claim Units The service unit for this claim Charges The charge amount submitted on the claim Paid Amount The payment amount made by MassHealth for the claim Status Status of claim Services Detail (Claim Information Received) Detail Used to link a list of services (Table continued on next page) Field Description Services Detail (Claim Information Received) Service Date Range of dates covered by this claim Charges The charge amount submitted on the claim Paid Amount The amount paid on this claim by MassHealth Service Code The service code for this claim Units The number of units billed by this provider Modifier(1) Code used to identify the modifiers connected to the service code Modifier(2) Code used to identify the modifiers connected to the service code Modifier(3) Code used to identify the modifiers connected to the service code Modifier(4) Code used to identify the modifiers connected to the service code Status Detail adjudication status of claim If you have any questions about how to use the Claim Status Inquiry and Response System, please call MassHealth Customer Service at 1-800-841-2900. Back Up/Restore Data Files It is recommended that the EVSpc software database tables be backed up on a regular basis. It is recommended that you back up your database tables a minimum of once per week. Backups may be performed using either the import/export procedure or the back up/restore procedure described below. The EVSpc software backs up the database by exporting copies of the tables in a text file format. These text files can be imported back into the database to restore the data. Member Information Table Backup To back up the member information table, do the following. 1. From the EVSpc Main Menu select Tools, Back-up, then Member Information. A window is displayed that allows you to save the back-up data to disk. 2. Choose a file name for saving the back-up data. The back-up process begins and the progress is displayed with a status bar. Upon completion, a window is displayed showing the number of records that were saved, and the name and location of the file in which they are stored. Restore Prior to restoring the member information table, all data must first be removed from the table. To remove all data from the table, do the following. 1. From the EVSpc Main Menu, select Member Information. 2. On the Search screen, click View All to display all the members in the table. 3. Select the Purge menu option. 4. Click Yes on the warning screen. All members in the table will now be deleted. 5. From the EVSpc Main Menu, select Tools, Restore, and then Member Information. 6. Select the file you wish to restore to the table. For example, “meminfo02042004.txt.” 7. Click Open. All records from the file are restored to the database. Upon completion, a window is displayed showing the number of records that were restored from the database. Backing Up Other Information The Backup/restore functionality discussed above for member information can also be used for inquiry history and batch key information. The inquiry history and batch key options are available along with member information. Another option is to back up all information in the database. Choosing “All” will back up member information, inquiry history, and batch key information. Note: Back-up files stored in the Back-up folder should be periodically deleted to recover space on your hard drive. Determine which back-up files are old and can be deleted, and delete them. The backed-up files can be compressed and stored on a diskette in order to recover the files from a disk crash. It is recommended that a utility such as WinZip be used to compress the files. It is recommended that you back up your Inquiry History periodically. EVSpc now has a limit of 10,000 inquiries in the Inquiry History database. You will not be able to perform inquiries when your inquiry history reaches this limit. Import/Export Data Files EVSpc backs up the database tables by exporting copies of the tables in a text file format. These text files can be imported back into the database to restore the data. Before exporting your files, a folder should be created on your hard drive to store the exported files. It is recommended to create the folder under the EVSpc software home directory in C:\ProgramFiles\EVSpc. Note: You must be logged out of EVSpc while exports and imports are being performed. When importing files from all tables, the Provider and Batch Key tables must be imported before the Member Information and Inquiry History tables. Export To export the Member Information table, do the following. 1. From the EVSpc Main Menu, select Member Information. 2. On the Search screen, click either View All to display all your members, or Cancel to display a blank screen. 3. From the File menu option, select Export. 4. Navigate to your export folder (for example, C:\Program Files\EVSpc\Export). 5. Type a name for your export file that will store all the exported data. You could also include the date of the export in the file name for easy reference. For example, an export of the Member Information table performed on February 4, 2011, might be named “Member02042011.txt.” 6. Click Open. The table is exported to the new file. Upon completion, a window is displayed showing the number of records that were exported. Import To import data from an exported file, all duplicate data to be restored must first be removed from the table. To remove all data from the table, do the following. 1. From the Main Menu, select Member Information. 2. On the Search screen, click View All to display all the members in the table. 3. Select the Purge menu option. 4. Click Yes on the warning screen when asked, “Do you want to delete all of the members in the display window from the database?” All members in the table will now be deleted. 5. From the File menu option, select Import. 6. Navigate to your export folder (for example, C:\Program Files\EVSpc\Export). 7. Select the file that you wish to import (for example, Member02042011.txt). 8. Click Open. All the records from the file are imported back into the table. Upon completion, a window is displayed showing the number of records that were imported. Import/Export Other Information Inquiry history and batch key information can also be exported or imported in the same way as member information. As described above, the export/import functionality is available in the Inquiry History screen and the Batch Key screen. Note: Disk maintenance must be performed as often as necessary to recover space. Contact Information If you have any questions about the software please contact MassHealth Customer Service at 1-800-841-2900. To submit comments or suggestions, document your feedback about the software and include NPI, provider name, provider number, contact name, and phone number, and then e-mail it to hipaasupport@mahealth.net. For comments or suggestions about policy information, please follow the above procedure. EVS-UG (Rev. 03/2012) EVSpc Software User Guide Page i March 2012