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-162 January 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Revised Appendix Y) Appendix Y has been updated to include modified messages that impact individuals eligible for, but unenrolled in Commonwealth Care who are also eligible for the Health Safety Net (HSN), and individuals enrolled in Commonwealth Care who are eligible to receive dental services through the HSN. HSN deductible amounts for these individuals have been updated to reflect the 2008 federal poverty level (FPL) income amounts. The deductible for individuals between 200 and 250% of the FPL has changed from $41 to $42. The deductible amount for individuals between 250 and 300% of the FPL has changed from $2,083 to $2,122. These changes are effective February 1, 2009. If you have any questions about the information in this transmittal letter please contact the Health Safety Net Help line at 1-877-910-2100. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manual Pages Y-1 through Y-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manual Pages Y-1 through Y-6 — transmitted by Transmittal Letter ALL-158 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. These messages are subject to change without notice. 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. 066 NETWORK HEALTH MEMBER. FOR MEDICAL SERVICES CALL 1-888-257-1985. FOR BEHAVIORAL HEALTH SERVICES CALL 1-888-257-1986. 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. 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 MASSHEALTH 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 MASSHEALTH 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. 391 SENIOR CARE OPTIONS. PAYMENT LIMITED TO SCO. AUTHORIZATION NEEDED FOR ALL SERVICES EXCEPT EMERGENCIES. CALL EVERCARE: 1-888-867-5511. Code Message 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 AT 1-888-816-6000 FOR AUTHORIZATION FOR ALL SERVICES EXCEPT FAMILY PLANNING, GLASSES, AND MOST DENTAL. 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 ELIGIBLE BUT NOT ENROLLED IN MANAGED CARE. SERVICE CANNOT BE BILLED TO MASSHEALTH. MEMBER MUST ENROLL. HSN COVERAGE AVAILABLE. 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 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 FOR ELIGIBILITY DATES AND PAYMENT FOR PRIMARY AND PREVENTIVE CARE SERVICES CALL CMSP AT 1-800-909-2677. Code Message 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. FOR VISION SERVICES CALL 1-888-257-1985. 617 NHP MEMBER. FOR DENTAL SERVICES CALL 1-800-341-8478. FOR VISION SERVICES CALL 1-800-638-3120. 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 1-800-822-5353. 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 ENROLLED WITH PLAN. COVERAGE TO BEGIN . 622 NETWORK HEALTH MEMBER. FOR VISION SERVICES CALL 1-888-257-1985. 623 NHP MEMBER. FOR VISION SERVICES CALL 1-800-638-3120. 624 BMC HEALTHNET PLAN MEMBER. FOR VISION SERVICES CALL 1-800-615-1883. 625 FALLON COMMUNITY HEALTH PLAN MEMBER. FOR VISION SERVICES CALL 1-800-868-5200. 628 COMMONWEALTH CARE PLAN TYPE I. MEMBER DOES NOT HAVE TO PAY A MONTHLY PREMIUM. MEMBER MUST PAY COPAYMENTS FOR PRESCRIPTION DRUGS. Code Message 629 COMMONWEALTH CARE PLAN TYPE II. MEMBER DOES NOT HAVE TO PAY A MONTHLY PREMIUM. MEMBER MUST PAY COPAYMENTS FOR SOME SERVICES. 630 COMMONWEALTH CARE PLAN TYPE II. MEMBER MUST PAY A MONTHLY PREMIUM AND COPAYMENTS FOR SOME SERVICES. 631 COMMONWEALTH CARE PLAN TYPE III. MEMBER MUST PAY A MONTHLY PREMIUM AND COPAYMENTS FOR SOME SERVICES. 632 COMMONWEALTH CARE PLAN TYPE IV. MEMBER MUST PAY A MONTHLY PREMIUM AND COPAYMENTS FOR SOME SERVICES. 633 HSN IS FOR CERTAIN HOSPITAL AND CHC SERVICES ONLY. MEMBER HAS SUBMITTED AN MBR AND IS NOT ELIG FOR MASSHEALTH. CALL 1-877-910-2100. 634 MEMBER MUST ENROLL IN COMMCARE TO RECEIVE THESE BENEFITS. MEMBER MUST CALL 1-877-MA-ENROLL (1-877-623-6765). 635 HSN AVAILABLE. 636 MEMBER IS ALSO ELIGIBLE FOR HSN SECONDARY. SEE 114.6 CMR 13.00 FOR INFO ON HSN REQS. 637 MEMBER IS HSN SECONDARY. BILL MEMBER’S PRIVATE HEALTH INSURANCE. SEE 130 CMR 450.316-317 FOR INFO ON TPL REQS. 638 PARTIAL HSN AVAILABLE. MEMBER WITH 200-250 PERCENT FPL. HSN DEDUCTIBLE IS $42. 639 PARTIAL HSN AVAILABLE. MEMBER WITH 250-300 PERCENT FPL. HSN DEDUCTIBLE IS $2,122. 640 HSN NOT AVAILABLE. 641 PARTIAL HSN AVAILABLE. 642 PARTIAL HSN DENTAL AVAILABLE. HSN DEDUCTIBLE IS $42. 643 PARTIAL HSN DENTAL AVAILABLE. HSN DEDUCTIBLE IS $2,122. 644 HSN DENTAL AVAILABLE 645 PARTIAL HSN DENTAL AVAILABLE 646 COPAY MAY BE APPLICABLE 647 HSN PHARMACY COPAYS MAY BE APPLICABLE. 648 HSN PHARMACY COPAYS MAY BE APPLICABLE. 650 MEMBER ALSO ELIGIBLE FOR COMMCARE: MEMBER MUST ENROLL TO RECEIVE THESE BENEFITS. CALL 1-877-MA-ENROLL (1-877-623-6765). 651 NEW MMIS MEMBER ID - 123456789012 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 450.118(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 1-800-833-7582 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.