Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER ALL-124
January 2004
TO:      All Providers Participating in MassHealth
FROM:      Beth Waldman, Acting Commissioner 
RE:      All Provider Manuals (Revisions to Appendix Y)
This letter transmits revisions to Appendix Y in all provider manuals. Appendix Y lists the active REVS (Recipient Eligibility Verification System) codes and their respective service-restriction messages. Providers accessing REVS to verify a member’s eligibility before providing medical services will receive one or more of the restriction messages. These revisions are effective February 1, 2004.
Appendix Y is also available on the MassHealth Web site at www.mass.gov/dma.
If you have any questions about this transmittal letter or REVS codes, please contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
All Provider Manuals
Pages Y-1 through Y-4
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
All Provider Manuals
Pages Y-1 through Y-4 — transmitted by Transmittal Letter ALL-117

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX Y: REVS CODES/MESSAGES	PAGE
Y-1	

	TRANSMITTAL LETTER
ALL-124	DATE
02/01/04	
This appendix lists the active REVS (Recipient Eligibility Verification System) codes and their respective service-restriction messages. Providers accessing REVS to verify a patient's eligibility before providing medical services will receive one or more of the following restriction messages.
Code	Message
006	NHP MEMBER. FOR MEDICAL SERVICES CALL 1-800-432-9449. FOR BEHAVIORAL
HEALTH SERVICES CALL 1-800-414-2820.
011	NHP MEMBER. FOR MEDICAL SERVICES CALL 1-800-432-9449. FOR BEHAVIORAL
HEALTH SERVICES CALL 1-800-414-2820.
021	BMC HEALTHNET MEMBER. FOR MEDICAL SERVICES CALL 1-888-566-0008. FOR
BEHAVIORAL HEALTH SERVICES CALL 1-888-217-3501.
031	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR EMERGENCIES.
CALL ESP OF THE NORTH SHORE AT 781-581-7565 OR 781-581-3900.
35	MASSHEALTH/DMH CLIENT.
36	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR EMERGENCIES. CALL ESP OF THE CAMBRIDGE HOSPITAL AT 617-868-6323.
041	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR EMERGENCIES.
CALL ESP AT FALLON AT 508-852-2026.
046	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR EMERGENCIES.
CALL ESP OF UPHAM’S CORNER AT 617-288-0970.
051	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR EMERGENCIES.
CALL HARBOR ELDER SERVICES AT 617-296-5100.
056	NETWORK HEALTH MEMBER. FOR MEDICAL SERVICES CALL 1-888-257-1985. FOR
BEHAVIORAL HEALTH SERVICES CALL 1-888-257-1986.
061	BMC HEALTHNET PLAN MEMBER. FOR MEDICAL SERVICES CALL
1-888-566-0008. FOR BEHAVIORAL HEALTH SERVICES CALL 1-888-217-3501.
066	NETWORK HEALTH MEMBER. FOR MEDICAL SERVICES CALL 1-888-257-1985. FOR
BEHAVIORAL HEALTH SERVICES CALL 1-888-257-1986.
071	MEMBER ENROLLED IN PROGRAM THAT LIMITS HIM/HER TO 1 PHARMACY. FOR
INFORMATION, MEMBER MAY CALL 1-800-841-2900, 8AM-5PM MON-FRI.
096	CARE MANAGEMENT PILOT PROGRAM MEMBER. PLEASE CALL 413-794-9428 TO
COORDINATE ALL MEDICAL AND BEHAVIORAL HEALTH SERVICES.
111	RESIDENT AT LONG-TERM-CARE FACILITY.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX Y: REVS CODES/MESSAGES	PAGE
Y-2	

	TRANSMITTAL LETTER
ALL-124	DATE
02/01/04	
Code	Message
116	EAEDC (CAT. 04). SERVICES RESTRICTED. SEE 130 CMR 450.106. FOR
QUESTIONS, CALL PROVIDER SERVICES AT 1-800-325-5231.
126	COMMUNITY CASE MANAGEMENT MEMBER. PRIOR AUTHORIZATION NOW
REQUIRED FOR HOME HEALTH (PDN, NURSING, HH AIDE, PCW) INFO 1-800-863-6068.
131	FALLON MEMBER. FOR MEDICAL SERVICES CALL 1-800-868-5200. FOR
BEHAVIORAL HEALTH SERVICES CALL 1-888-421-8861.
171	PRIOR AUTHORIZATION MANDATORY FOR ALL CARE EXCEPT FOR
EMERGENCIES. CALL ESP OF EAST BOSTON AT 617-568-6416 OR EVES AT 617-568-4470.
186	EXEMPT FROM COPAY ON NON-PHARMACY SERVICES UNDER 130 CMR
450.130(D).
246	EXEMPT FROM COPAY ON PHARMACY SERVICES UNDER 130 CMR 450.130(D).
271	MET CAP ON NON-PHARMACY SERVICES UNDER 130 CMR 450.130(C).
311	FALLON MEMBER. FOR MEDICAL SERVICES CALL 1-800-868-5200. FOR
BEHAVIORAL HEALTH SERVICES CALL 1-888-421-8861.
366	MET CAP ON PHARMACY SERVICES UNDER 130 CMR 450.130(C).
386	MEDICARE-COVERED SERVICES ONLY.
391	SENIOR CARE OPTIONS. PAYMENT LIMITED TO SCO. AUTHORIZATION
NEEDED FOR ALL SERVICES EXCEPT EMERGENCIES. CALL EVERCARE: 888-867-5511.
461	PRIMARY CARE CLINICIAN (PCC) PLAN MEMBER. CALL PCC FOR
AUTHORIZATION FOR ALL SERVICES EXCEPT THOSE LISTED IN 130 CMR 450.118(I).
480	BILL MEMBER’S PRIVATE HEALTH INSURANCE. MASSHEALTH PAYS ONLY
FOR COPAYS AND DEDUCTIBLES.
485	BILL MEMBER’S PRIVATE HEALTH INSURANCE. MASSHEALTH PAYS ONLY
FOR COPAYS AND DEDUCTIBLES FOR WELL-CHILD VISITS.
490	DMH-COVERED SERVICES ONLY. NOT ELIGIBLE FOR MASSHEALTH.
495	ELIGIBLE FOR PREMIUM ASSISTANCE ONLY. BILL MEMBER'S PRIVATE
HEALTH INSURANCE.
500	SPECIAL NHP PROGRAM. CALL NHP FOR AUTHORIZATION FOR ALL SERVICES
EXCEPT FAMILY PLANNING, GLASSES, AND MOST DENTAL. 1-888-816-6000

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX Y: REVS CODES/MESSAGES	PAGE
Y-3	

	TRANSMITTAL LETTER
ALL-124	DATE
02/01/04	
Code	Message
505	MASSHEALTH COMMONHEALTH MEMBER. FOR QUESTIONS, CALL
1-800-325-5231.
516	CALL HRCA AT 617-325-8000 FOR AUTHORIZATION OF ALL SERVICES EXCEPT
ACUTE INPATIENT ADMISSIONS.
520	ELIGIBLE FOR AMBULATORY PRENATAL CARE ONLY.
522	ELIGIBLE FOR EMERGENCY SERVICES ONLY.
525	FOR MENTAL HEALTH OR SUBSTANCE ABUSE SERVICE AUTHORIZATION,
CALL THE PARTNERSHIP AT 1-800-495-0086.
530	NO PCC/MCO AUTHORIZATIONS NEEDED. FOR MH/SA SERVICE
AUTHORIZATION, CALL THE PARTNERSHIP AT 1-800-495-0086.
545	DMH CLIENT. NOT ELIGIBLE FOR MASSHEALTH. HAS OTHER HEALTH
INSURANCE: TPL AND/OR MEDICARE.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX Y: REVS CODES/MESSAGES	PAGE
Y-4	

	TRANSMITTAL LETTER
ALL-124	DATE
02/01/04	
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