Part 1.  Eligibility
The MassHealth Card
The MassHealth card identifies a person as being a MassHealth member. However, it does not 
guarantee that the cardholder is eligible for the specific date or date range of service, or that 
MassHealth will pay for the services. Therefore, the provider should request to see the card and must 
access the eligibility verification system (EVS) to verify eligibility for a specific date or range of 
dates. 
Examples of the MassHealth card may be found in the EVS User Guide. You can download it at 
www.mass.gov/masshealth/newmmis. Click on Read Updated Billing Guides, Companion Guides, and 
Other Publications. 
Verifying Eligibility
EVS provides you with eligibility information for all MassHealth members. By verifying a member’s 
eligibility on the day or date range of service, you may be able to reduce the risk of your claims being 
denied. 
All providers are required to have a user ID and password to use EVS. To obtain a user ID and 
password, each provider must sign a MassHealth Trading Partner Agreement (TPA). 
To access EVS, go to the Provider Online Service Center at 
www.mass.gov/masshealth/providerservicecenter.
For providers who conduct electronic eligibility verification transactions, and have Internet access, 
the following options are available:
*	Provider Online Service Center; and
*	Third-party vendor software.
All these methods can be used for eligibility verification, while some of these methods can also be 
used to check the status of a claim that has been fully processed by MassHealth.
Providers without Internet access can call the automated voice response (AVR) system at  
1-800-554-0042 or call the eligibility operator at 1-800-841-2900. Contact information for 
MassHealth Customer Service appears in Appendix A of your provider manual. Active EVS codes 
and their respective service restriction messages are available in Appendix Y of your provider manual. 
You may also refer to the EVS User Guide for more information about these and other access 
methods. Go to www.mass.gov/masshealth/newmmis and click on Read Updated Billing Guides, 
Companion Guides, and Other Publications.
Trading Partner Agreements (TPAs)
To access EVS, an authorized MassHealth provider must first have submitted a signed TPA. The 
primary contact for the Health Insurance Portability and Accountability Act (HIPAA) at your 
organization should be able to tell if there is a signed TPA on file. The TPA is part of the MassHealth 
provider enrollment packet. To navigate to the TPA document, go to www.mass.gov/masshealth. In 
the lower right section of the home page, under Publications, click on MassHealth Provider Forms. 
Select the Trading Partner Agreement from the list of forms.
Other related information is available on the MassHealth Web site in the MassHealth Provider Forms 
section. To navigate to the page, go to www.mass.gov/masshealth. In the lower right section of the 
home page, under Publications, click on MassHealth Provider Forms.
User ID and Password
You must have a valid user ID and password to access EVS. To determine if you have a valid user ID 
and password, call the EVS Help Desk after submitting the signed TPA referred to in the preceding 
section. Details about the user ID and password may be found in the EVS User Guide.
HIPAA Compliance
EVS meets the ANSI ASC X12N 270/271 Health Care Eligibility Benefit Inquiry and Response 
standards. Data transmissions to and from the Provider Online Service Center meet the security 
standards of the HIPAA security regulations. Associated companion guides for the HIPAA 270/271 
transactions are available on the MassHealth Web site. To navigate to the companion guides, go to 
www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on 
Provider Library. 
Security and Privacy
Your current MassHealth provider agreement, in combination with the TPA, requires you to make 
every effort to secure and protect information transmitted to and from our system. The HIPAA Privacy 
Rule (45 CFR Part 164.500, et seq.) governs uses and disclosures of protected health information. 
MassHealth’s Data Protection Policies and Procedures contain information on workforce compliance 
with state and federal confidentiality laws for reference.
Explanation of MassHealth Coverage Types
Based on eligibility requirements, MassHealth members receive benefits according to specific 
coverage types. EVS provides the member’s coverage type as part of the eligibility verification 
transaction. Providers should refer to MassHealth regulations at 130 CMR 450.105 for a list of 
covered services by coverage type and for other information and requirements about each coverage 
type. Provider regulations are available on our Web site at www.mass.gov/masshealth in the Provider 
Library.

Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
5. Administrative and Billing 
Instructions
Page
5.1-1
All Provider Manuals
Transmittal Letter
ALL-165
Date
05/26/09