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-144 December 2006 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: All Provider Manuals (Revised Appendix Y) Appendix Y has been updated to include additional REVS messages that do not have REVS restrictive message codes associated with them. These messages, however, are still important to understand before providing services. These new messages are listed on Page Y-5 under “Other Messages.” Effective December 8, 2006, several new messages will begin to appear on REVS. The first message is related to enrollment in a Commonwealth Care managed care organization (MCO). When a member is eligible for Commonwealth Care coverage, but has yet to select a Commonwealth Care MCO, the following message appears in REVS: 620 MEMBER ALSO ELIGIBLE FOR COMMONWEALTH CARE. MEMBER MUST ENROLL IN MANAGED CARE TO RECEIVE THESE BENEFITS. CALL 1-877-MAENROLL. When a member is eligible for Commonwealth Care and has selected or been assigned to a Commonwealth Care MCO, but the coverage is not yet effective, the following message will appear in REVS: 621 MEMBER ALSO ELIGIBLE FOR COMMONWEALTH CARE. ENROLLED WITH PLAN. COVERAGE TO BEGIN . In this message, is the name of the Commonwealth Care MCO selected by or assigned to the member and represents the effective date of Commonwealth Care coverage (three letters for the month and two digits for the year – for example, Dec 06). All Commonwealth Care enrollments begin on the first day of a calendar month. This change is effective for all access methods, except for the Automated Voice Response (AVR) system, which will be updated at a later date. Please note that a member’s eligibility may change or the member can change their Commonwealth Care MCO prior to the effective date of coverage. As always, check REVS before providing services. MASSHEALTH TRANSMITTAL LETTER ALL-144 December 2006 Page 2 Another new message will appear when a MassHealth member has had more than one member identification number (ID) in REVS. In certain situations a member’s previous member ID may no longer be valid when submitting a claim to MassHealth. To help ensure that you submit the proper member ID for a member, REVS will return: “Member is Eligible - Use this RID for this Date of Service Only” This message indicates that the member you are providing services for has more than one member ID on REVS. As a result, the member ID you requested is not the member ID you should submit on the claim for that date of service. However, the member ID you queried is still considered active and should be used in future inquiries on REVS. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages Y-1 through Y-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages Y-1 through Y-6 — transmitted by Transmittal Letter ALL-142 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-1 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 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 9118 Hingham, MA 02043 Fax: 617-988-8973 E-mail: publications@mahealth.net This appendix lists the active Recipient Eligibility Verification System (REVS) 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. This appendix also lists other messages that do not have a code associated with them, but are important to be aware of, as they are returned on REVS. Code Message 006 NHP MEMBER. FOR MEDICAL SERVICES CALL 1-800-462-5449. FOR BEHAVIORAL HEALTH SERVICES CALL 1-800-414-2820. 011 NHP MEMBER. FOR MEDICAL SERVICES CALL 1-800-462-5449. FOR BEHAVIORAL HEALTH SERVICES CALL 1-800-414-2820. 021 BMC HEALTHNET MEMBER. FOR MEDICAL SERVICES CALL 1-888-566-0010. FOR BEHAVIORAL HEALTH SERVICES CALL 1-888-217-3501. 031 PRIOR AUTH REQUIRED ON ALL CARE EXCEPT EMERGENCIES. ESP NORTH SHORE. CALL 781-581-3900 FOR LYNN CLIENTS, 978-837-9479 FOR BEVERLY CLIENTS. 035 DMH CLIENT. 036 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 1-888-566-0010. FOR BEHAVIORAL HEALTH SERVICES CALL 1-888-217-3501. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-2 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 Code Message 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. 075 MEMBER ID MAY HAVE BEEN USED IN THE PAST BY MORE THAN ONE MASSHEALTH MEMBER. VERIFY MEMBER NAME AND BIRTHDATE ON RESPONSE. 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 1-800-841-2900. 121 DIRECT ALL INQUIRIES ABOUT ELIGIBILITY TO SOCIAL SERVICE WORKER. 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. 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 1-877-910-2100. 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 MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-3 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 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. SEE 130 CMR 450.316-317 FOR INFO ON TPL REQS AND PAYMENT LIMITATIONS ON CLAIM SUBMISSIONS. 485 BILL MEMBER’S PRIVATE HEALTH INSURANCE. MASSHEALTH PAYS ONLY FOR COPAYS AND DEDUCTIBLES FOR WELL-CHILD VISITS. 490 DMH CLIENT. 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 1-800-841-2900. 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. 595 MEMBER ELIGIBLE BUT NOT ENROLLED IN MANAGED CARE. SERVICE CANNOT BE BILLED TO MASSHEALTH. MEMBER MUST CALL CUSTOMER SERVICE 1-800-841-2900. 596 MEMBER ALSO ELIGIBLE FOR ESSENTIAL. MEMBER MUST ENROLL IN MANAGED CARE TO RECEIVE THESE BENEFITS. MEMBER MUST CALL 800-841-2900. 597 MEMBER ALSO ELIGIBLE FOR BASIC. MEMBER MUST ENROLL IN MANAGED CARE TO RECEIVE THESE BENEFITS. MEMBER MUST CALL 800-841-2900. 601 ELIGIBLE FOR EMERGENCY SERVICES, INCLUDING LABOR AND DELIVERY, UNDER LIMITED WITHOUT COPAY UNDER 130 CMR 450.130(D). 602 FOR ELIGIBILITY DATES AND PAYMENT FOR ALL OTHER PREGNANCYRELATED SERVICES UNDER HEALTHY START, CALL 1-888-488-9161. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-4 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 Code Message 603 ELIGIBLE FOR EMERGENCY SERVICES UNDER LIMITED WITHOUT COPAY UNDER 130 CMR 450.130(D). 604 FOR ELIGIBILITY DATES AND PAYMENT FOR PRIMARY AND PREVENTIVE CARE SERVICES CALL CMSP AT 1-800-909-2677. 605 FOR ELIGIBILITY DATES AND PAYMENT FOR PRIMARY AND PREVENTIVE CARE SERVICES CALL CMSP AT 1-800-909-2677. 606 REIMBURSEMENT FROM THE UNCOMPENSATED CARE POOL NOT ALLOWABLE FOR THIS PATIENT. FOR INFORMATION CALL 617-988-3222 OR 1-877-910-2100. 608 MEMBER ELIGIBLE FOR MEDICARE PART D. FOR MEMBER ENROLLMENT STATUS OR OTHER INFORMATION CALL 1-800-MEDICARE (1-800-633-4227). 609 YES. MEMBER HAS FULL MEDICAID BENEFITS. 610 NO. MEMBER DOES NOT HAVE FULL MEDICAID BENEFITS. 611 MEMBER IS QUALIFIED MEDICARE BENEFICIARY. SEE 130 CMR 519.010. 612 MEMBER IS SPECIFIED LOW INCOME MEDICARE BENEFICIARY. SEE 130 CMR 519.011(A). 613 MEMBER IS QUALIFIED INDIVIDUAL BENEFICIARY. SEE 130 CMR 519.011(B). 614 BILL HOSPICE PROVIDER IF SERVICE IS RELATED TO TERMINAL ILLNESS. 615 BMC HEALTHNET PLAN MEMBER. FOR MEDICAL SERVICES CALL 1-888-566-0008. FOR BEHAVIORAL HEALTH SERVICES CALL 1-866-444-5155. 616 NETWORK HEALTH MEMBER. FOR DENTAL SERVICES CALL 1-800-341-8478. 617 NHP MEMBER. FOR DENTAL SERVICES CALL 1-800-685-9971. FOR VISION SERVICES CALL 1-800-462-5449. 618 BMC HEALTHNET PLAN MEMBER. FOR DENTAL SERVICES CALL 1-800-685-9971. FOR VISION SERVICES CALL 1-800-615-1883. 619 FALLON COMMUNITY HEALTH PLAN MEMBER. FOR DENTAL SERVICES CALL 1-800-868-5200. FOR VISION SERVICES CALL 1-800-868-5200. 620 MEMBER ALSO ELIGIBLE FOR COMMONWEALTH CARE. MEMBER MUST ENROLL IN MANAGED CARE TO RECEIVE THESE BENEFITS. CALL 1-877-MA-ENROLL. 621 MEMBER ALSO ELIGIBLE FOR COMMONWEALTH CARE. ENROLLED WITH PLAN. COVERAGE TO BEGIN . Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-5 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 Other Messages This section lists messages returned from REVS that do not have a code associated with them. While they do not have an associated code, these messages are still important when providing services. Member is Eligible Member is eligible based on the services and restrictions indicated for the date of service inquired upon. Member is Eligible – RID has changed Member is eligible based on the services and restrictions indicated for the date of service inquired upon. The member ID inquired upon for this member has changed. The new member ID is displayed and should be used for billing purposes. Member is Not Eligible Member is not eligible on date of service inquired upon. Member was eligible for benefits at some time in the 13 months prior to the date of inquiry. Member Not Found Member is not known to REVS. Member is Eligible - Use this RID for this Date of Service Only Member is eligible based on the services and restrictions for the date of service inquired upon. However, the member ID that you need to submit on the claim for payment differs from the member ID that you entered in REVS. Submit the claim with the member ID returned but use the member ID you entered in REVS for future eligibility inquiries. PCC Member. Call (corporate & site name, if applicable) (phone number) for approval. For exceptions see 130 CMR 450.11.8(J) Member is enrolled with a Primary Care Clinician (PCC.) The corporate PCC and site PCC (if applicable) names will be displayed. The site PCC phone number will be displayed. Duplicate RID. Call 1-800-8337582 for assistance. The member ID entered has been linked to more than one member on REVS. Call the Eligibility Operator to determine the appropriate member ID to check eligibility. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. REVS Codes/Messages Page Y-6 All Provider Manuals Transmittal Letter ALL-144 Date 12/01/06 This page is reserved.