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-129
December 2004

TO:
FROM:
RE:

All Providers Participating in MassHealth
Beth Waldman, Medicaid Director
All Provider Manuals (Provider Manual Appendices)

Revised 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 listed in this appendix.
Provider Manual Appendices on MassHealth Web Site
Effective 12/1/04, MassHealth will no longer mail updates to the following all provider manual appendices.
Appendix A.  Directory
Appendix B.  MassHealth Enrollment Centers
Appendix C.  Third-Party Liability Carrier Codes
Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule
Appendix X.  Family Assistance Copayments and Deductibles
Appendix Y.  REVS Codes/Messages
Appendix Z.   EPSDT Services Laboratory Codes
To view, download, or print the most up-to-date version of the above provider manual appendices, go to www.mass.gov/masshealthpubs. Click on “Provider Library,” then click on “Provider Manual Appendices.” Soon, providers will be able to sign up to receive e-mail notification anytime MassHealth updates any of the above appendices on the Web site. Providers should watch for this e-mail notification feature on the Provider Manual Appendices Web page. Please also note that Appendix C is being updated in December.
If needed, you may request a paper copy of the most up-to-date of any of the above appendices at the following address or fax numbers.
MassHealth Publications
P.O. Box 9101
Somerville, MA 02145
Fax: 617-576-4487 or 703-917-4943
If you have any questions about the information in this transmittal letter, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

MASSHEALTH
TRANSMITTAL LETTER ALL-129 December 2004 Page 2
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(The pages listed here are no longer in effect.)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-128

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-129	DATE
12/01/04	
REVS Codes and Messages
Important Note: This appendix is available online at www.mass.gov/masshealthpubs. MassHealth will update Appendix Y as needed. Paper copies of this appendix will not be mailed automatically, but can be requested by mailing, faxing, or e-mailing a request to:
MassHealth Publications
P.O. Box 9101
Somerville, MA 02145
Fax: 617-576-4487
E-mail: mapublications@unisys.com
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.

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-129	DATE
12/01/04	
Code	Message
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.
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).
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 NEEDED
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 SERVICES
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.

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-129	DATE
12/01/04	
Code	Message
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 IN 130 CMR 450.118(J).
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 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
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
601	
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-129	DATE
12/01/04	
Code	Message
606	REIMBURSEMENT FROM THE UNCOMPENSATED CARE POOL NOT
ALLOWABLE FOR THIS PATIENT. FOR INFORMATION CALL 617-988-3222 OR 1-877-910-2100