Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ALL-128 September 2004 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Director, Office of Medicaid 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. Revisions to the REVS codes include the following: • additional coverage types; • deductible amounts (applicable for the Partial Free Care Coverage type); and • restrictive messages. These revisions are effective October 1, 2004. Senior Care Options (SCO) Providers will now receive the following message for members enrolled in the new Senior Care Organization, Senior Whole Health: (231) Senior Care Options. Payment limited to SCO. Authorization needed for all services except emergencies. Call SWH: 888-794-7268. Low Income Patients (Free Care) Providers will begin to receive appropriate service restriction messages for low-income patients covered by the Uncompensated Care Pool. This includes those low-income patients who receive Partial or Full Free Care. The providers who can perform services for low-income patients are limited to acute hospitals and community health centers. All other providers will not be reimbursed for services provided to low- income patients. MASSHEALTH TRANSMITTAL LETTER ALL-128 September 2004 Page 2 For providers who are eligible to perform services, the restrictive message will read: (281) Uncompensated Care Pool is for certain hospital and CHC services only. For more information, call 617-988-3222. Those providers who are not eligible to provide services will be receive the following restrictive message: (306) Individual has submitted an MBR and is not eligible for MassHealth. For more information, call 1-800-462-7738. Y-Recipient Identification Number (RID) In an effort to effectively identify those members receiving services from DYS (Department of Youth Services), MassHealth will append the letter 'Y' to the beginning of the respective eight-digit MID# in place of the currently used prefix '990.' Please note: The modification to the MID# is designed for identification purposes only and does not affect member eligibility or services that can or cannot be provided. Children's Medical Security Plan (CMSP) and Healthy Start Program (HSP) As of July 1, 2004, MassHealth became responsible for administering the Children's Medical Security Plan (CMSP) and the Healthy Start Program (HSP). Providers will receive the appropriate restrictive message for members covered by CMSP and HSP. Healthy Start members will also receive MassHealth Limited benefits. These members will be displayed under the new coverage type: LMTD HLTHY STRT. Some CMSP members will also have MassHealth Limited benefits, and the coverage type will be displayed as LMTD CMSP. Many other CMSP members will not be eligible for MassHealth Limited. The new coverage type for CMSP members without Limited coverage will be CMSP ONLY. Children's Medical Security Plan (CMSP) and Healthy Start (HSP) services should continue to be billed to UNICARE. All claims for MassHealth Limited services should continue to be billed to MassHealth. For new members with coverage type LMTD HLTHY STRT, the following new REVS restrictive messages will be displayed: (601) Eligible for emergency services, including labor and delivery, under Limited without copay under 130 CMR 450.130(D). (602) For information on and payment of all other pregnancy-related services under Healthy Start, call 1-888-488-9161. MASSHEALTH TRANSMITTAL LETTER ALL-128 September 2004 Page 3 For new members with coverage type LMTD CMSP, the following new REVS restrictive messages will be displayed: (603) Eligible for emergency services under Limited without copay under 130 CMR 450.130(D). (604) Eligible for primary and preventive care services. Call CMSP at 1-800-909-2677. For new members with coverage type CMSP ONLY, the following new REVS restrictive message will be displayed: (605) Eligible for primary and preventive care services only. Call CMSP at 1-800-909-2677. Appendix Y is also available on the MassHealth Web site at www.mass.gov/masshealthpubs. 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-127 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. 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 COP AY ON NON-PHARMACY SERVICES UNDER 130 CMR 450.130(D). 201 SENIOR CARE OPTIONS. PAYMENT LIMITED TO SCO. AUTHORIZATION NEEDED FOR ALL SERVICES EXCEPT EMERGENCIES. CALL CCA: 1-866-610-2273. 231 SENIOR CARE OPTIONS. PAYMENT LIMITED TO SCO. AUTHORIZATION NEEDE FOR ALL SERVICES EXCEPT EMERGENCIES. CALL SWH: 1-888-794-7268. 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). 281 UNCOMPENSATED CARE POOL IS FOR CERTAIN HOSPITAL AND CHC SERVICE ONLY. FOR MORE INFORMATION, CALL 617-988-3222. 306 INDIVIDUAL HAS SUBMITTED AN MBR AND IS NOT ELIGIBLE FOR MASSHEALTH. FOR MORE INFORMATION, CALL 1-800-462-7738. 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: 1-888-867-5511. 461 PRIMARY CARE CLINICIAN (PCC) PLAN MEMBER. CALL PCC FOR AUTHORIZATION FOR ALL SERVICES EXCEPT THOSE LISTED EN 130CMR450.118(J). Code Message 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 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. 601 ELIGIBLE FOR EMERGENCY SERVICES, INCLUDING LABOR AND DELIVERY, UNDER LIMITED WITHOUT COP AY UNDER 130 CMR 450.130(D) 602 FOR INFORMATION ON AND PAYMENT OF ALL OTHER PREGNANCY-RELATED SERVICES UNDER HEALTHY START, CALL 1-888-488-9161 603 ELIGIBLE FOR EMERGENCY SERVICES UNDER LIMITED WITHOUT COPAY UNDER 130 CMR 450.130(D) 604 ELIGIBLE FOR PRIMARY AND PREVENTIVE CARE SERVICES. CALL CMSP AT 1-800-909-2677 605 ELIGIBLE FOR PRIMARY AND PREVENTIVE CARE SERVICES ONLY. CALL CMSP AT 1-800-909-2677