Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter ALL-204 October 2013 TO: All Providers Participating in MassHealth FROM: Kristin L. Thorn, Medicaid Director RE: All Provider Manual (Revised Appendix Y) One Care: MassHealth plus Medicare Program MassHealth and Medicare, in partnership with three Massachusetts health plans, have joined together to offer One Care. One Care is a comprehensive health program designed to fully integrate MassHealth and Medicare benefits for dually eligible members who are between the ages of 21 and 64 at the time of enrollment. Contracted plans are identified below. Self-selection for One Care plans began September 3, 2013, for an enrollment effective date of October 1, 2013. Enrollment in One Care plans will remain open thereafter. MassHealth will auto-enroll certain eligible individuals who did not exercise their option to choose a One Care plan or tell us that they do not want to participate. The coverage effective date for the first wave of auto-enrollment is January 1, 2014. Future auto-enrollment waves are planned with coverage effective dates of April 1, 2014, and July 1, 2014. Individuals will receive information from MassHealth notifying them of an auto-assignment in advance of their enrollment. The following new messages have been added to the Eligibility Verification System (EVS) to identify a MassHealth member enrolled in a One Care plan. Unique Message # Restrictive Message Text 667 One Care. Commonwealth Care Alliance member. For medical, behavioral health, and long-term services and support services, call 1-866-610-2273. 668 One Care. Fallon Total Care member. For medical, behavioral health, and long-term services and support services, call 1-855-508-4715. 669 One Care. Network Health member. For medical, behavioral health, and long- term services and support services, call 1-888-257-1985. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions 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 All Provider Manual Pages Y-1 through Y-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.)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-193 MassHealth Transmittal Letter ALL-204 October 2013 Page 2 EVS Codes and Messages Important Note: This appendix is available online at www.mass.gov/masshealthpubs. MassHealth updates 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 the following address. MassHealth Publications P.O. Box 9118 Hingham, MA 02043 Fax: 617-988-8973 E-mail: publications@mahealth.net This appendix lists the active Eligibility Verification System (EVS) system-generated message numbers, their corresponding unique message numbers, and their respective restrictive message text. Providers accessing EVS through the Provider Online Service Center (POSC) to verify a patient's eligibility before providing medical services will receive one or more of the following restrictive messages. These messages are subject to change without notice. EVS System- Generated Message # Unique Message # Restrictive Message Text 10 6 NHP member. For medical services, call 1-800-462-5449. For behavioral health services, call 1-800-414-2820. 747-749 21 BMC HealthNet member. For medical services, call 1-888-566-0010. For behavioral health services, call 1-888-217-3501. 12 31 Prior authorization required on all care except emergencies. ESP North Shore. Call 781-581-3900 for Lynn clients; 978-837-9479 for Beverly clients. 1 35 DMH client. 13 36 Prior authorization mandatory for all care except for emergencies. Call ESP of The Cambridge Hospital at 617-868-6323. 14 41 Prior authorization mandatory for all care except for emergencies. Call ESP of Fallon at 508-852-2026. 15 46 Prior authorization mandatory for all care except for emergencies. Call ESP of Upham's Corner at 617-288-0970. 16 51 Prior authorization mandatory for all care except for emergencies. Call Harbor Elder Services at 617-296-5100. 1103-1109, 1130, 1140- 1147 56 Network Health member. For medical services, call 1-888-257-1985. For behavioral health services, call 1-888-257-1985. 71 71 Member enrolled in program that limits him/her to one pharmacy. For information, member may call 1-800-841-2900, 8:00 A.M.-5:00 P.M., Mon.- Fri. 2 111 Resident at long-term-care facility 3 116 EAEDC (Cat. 04). Services restricted. See 130 CMR 450.106. For questions, call provider services at 1-800-841-2900. 121 121 Direct all inquiries about eligibility to Social Service Worker. 68 126 Community Case Management (CCM) member. Prior authorization required for nursing, home health, and PCA services. Contact CCM at 1-800-863-6068. 19 171 Prior authorization mandatory for all care except for emergencies. Call ESP of East Boston at 617-568-6416. 186 186 Exempt from copay on nonpharmacy services under 130 CMR 450.130(D). 20 201 Senior Care Options. Payment limited to SCO. Authorization needed for all services except emergencies. Call CCA: 1-866-610-2273. 21 231 Senior Care Options. Payment limited to SCO. Authorization needed for all services except emergencies. Call SWH: 1-888-794-7268. 246 246 Exempt from copay on pharmacy services under 130 CMR 450.130(D). 271 271 Member has met cap on nonpharmacy services under 130 CMR 450.130(C). 740-746 311 Fallon member. For medical services, call 1-866-275-3247. For behavioral health services, call 1-888-421-8861. 366 366 Member has met cap on pharmacy services under 130 CMR 450.130(C). 827, 831, 832, 840, 841 386 Medicare-covered services only 28 391 Senior Care Options. Payment limited to SCO. Authorization needed for all services except emergencies. Call Evercare: 1-888-867-5511. 461 461 Primary Care Clinician (PCC) Plan member. Call PCC for authorization for all services except those listed in 130 CMR 450.118(J). 5, 6 480 Bill member's private health insurance. See 130 CMR 450.316-317 for information on TPL requests and payment limitations on claim submissions. 7, 8 485 Bill member's private health insurance. MassHealth pays for copays and deductibles for well-child visits. 74 490 DMH client who is not eligible for MassHealth. 29-32 495 Eligible for Premium Assistance. Bill member's private health insurance. 773 500 Special NHP program. Call NHP at 1-888-816-6000 for authorization for all services except family planning, glasses, and most dental. 33 505 MassHealth CommonHealth member. For questions, call 1-800-841-2900. 9 516 Call HRCA at 617-325-8000 for authorization of all services except acute inpatient admissions. 34 520 Eligible for ambulatory prenatal care only. 35 522 Eligible for emergency services only. 76 525 For mental health or substance abuse service authorization, call MBHP at 1-800-495-0086. 530 530 No PCC/MCO authorizations needed. For MH/SA service authorization, call MBHP at 1-800-495-0086. 550 550 Retro HSN available 551 551 Retro Partial HSN available. HSN deductible is $XX.XX. 596 596 Member is eligible for Essential but not enrolled. Member must call 1-800-841-2900 and enroll in Managed Care to receive these benefits. HSN is available. 597 597 Member eligible for Basic but not enrolled. Member must call 1-800-841-2900 and enroll in Managed Care to receive these benefits. HSN is available. 40 601 Eligible for emergency services, including labor and delivery, under Limited without copay under 130 CMR 450.130(D). 41 602 For eligibility dates and payment for all other pregnancy-related services under Healthy Start, call 1-888-488-9161. 42 603 Eligible for emergency services under Limited without copay under 130 CMR 450.130(D). 43 604 For eligibility dates and payment for primary and preventive care services, call CMSP at 1-800-909-2677. 44, 760-761, 842-848 606 Patient is not eligible for services paid by the Health Safety Net. For information, call 617-988-3222 OR 1-877-910-2100. 45 608 Member eligible for Medicare Part D. For member enrollment status or other information, call 1-800-MEDICARE (1-800-633-4227). 80, 106-120, 122-201, 700-701 609 Yes. Member has full Medicaid benefits. 81, 202-245, 247-270, 272-298, 702 610 No. Member does not have full Medicaid benefits. 46, 766 611 Member is Qualified Medicare Beneficiary. See 130 CMR 519.010. 48, 49 612 Member is Specified Low Income Medicare Beneficiary. See 130 CMR 519.011(A). 50, 51 613 Member is Qualified Individual Beneficiary. See 130 CMR 519.011(B). 614 614 Bill hospice provider if service is related to terminal illness. 53, 750-752 615 BMC HealthNet member. For medical services, call 1-888-566-0010. For behavioral health services, call 1-888-217-3501. 1050-1053, 1110-1113, 1131, 1139, 1148, 1183, 1186-1190 616 Network Health member. For dental services, call 1-888-257-1985. For vision services, call 1-888-257-1985. 1054-1057, 1191, 1192 617 NHP member. For dental services, call 1-800-685-9971. For vision services, call 1-800-462-5449. 1058-1061, 1193-1194 618 BMC HealthNet member. For medical services, call 1-888-566-0010. For behavioral health services, call 1-888-217-3501. 1062-1065, 1195-1196 619 Fallon Community Health Plan member. For dental services, call 1-866-275-3247. For vision services, call 1-866-275-3247. 621 621 Member enrolled in Commonwealth Care effective the first day of the upcoming calendar month. Call 1-800 841-2900 for more information. 1066-1069, 1114-1117, 1132-1135, 1197-1198, 1200-1212 622 Network Health Member. For vision services, call 1-888-257-1985. 1070-1073, 1178-1182 623 NHP member. For vision services, call 1-800-462-5449. 1074-1077, 1167-1172 624 BMC HealthNet Plan member. For vision services, call 1-800-877-7195. 1078-1081, 1173-1177 625 Fallon Community Health Plan member. For vision services, call 1-866-275-3247. 1082, 1165- 1166 628 Commonwealth Care Plan Type I. Member does not have to pay a monthly premium. Member must pay copayments for prescription drugs. 1083, 1163- 1164 629 Commonwealth Care Plan Type II. Member may have to pay a monthly premium. Member must pay copayments for some services 1084, 1162 630 Commonwealth Care Plan Type II. Member must pay a monthly premium and copayments for some services. 1085-1086, 1161 631 Commonwealth Care Plan Type III. Member must pay a monthly premium and copayments for some services. 632 632 Commonwealth Care Plan Type IV. Member must pay a monthly premium and copayments for some services. 633, 1218- 1229 633 HSN is for certain hospital and CHC services only. Member has submitted an MBR and is not eligible for MassHealth. Call 1-877-910-2100. 1087-1091, 1151, 1153- 1158 634 Member must enroll in CommCare to receive these benefits. Member must call 1-877-MA-ENROLL (1-877-623-6765). 635 635 HSN available. 853-910, 912, 913 636 Member is also eligible for HSN Secondary. See 114.6 CMR 13.00 for info on HSN requirements. 791-792 637 Member is HSN Secondary. Bill member’s private health insurance. See 114.6 CMR 13.00 for info on TPL requirements. 638 638 Partial HSN available. Member with 200-250 percent FPL. HSN deductible is $45 639 639 Partial HSN available. Member with 250-300 percent FPL. HSN deductible is $2,234. 640 640 HSN not available 641 641 Partial HSN available 1092, 1213 642 Partial HSN dental available. Member with 200-250 percent FPL. HSN deductible is $45. 1093, 1214 643 Partial HSN dental available. Member with 250-300 percent FPL. HSN deductible is $2,234. 1094-1095, 1215-1217 644 HSN dental available 89, 771, 772 646 NHP member. For vision services, call 1-800-462-5449. 915 647 HSN medical and pharmacy copays may be applicable. 770 648 HSN pharmacy copays may be applicable. 650 650 Member’s MassHealth eligibility is temporary. 916 651 CeltiCare member. For medical services, call 1-866-895-1786. For behavioral health services, call 1-866-896-5053. 917 652 CeltiCare member. For dental services, call 1-866-895-1786. For vision services, call 1-866-895-1786. 918-921 653 CeltiCare member. For vision services, call 1-866-895-1786. 936-942 656 Member eligible for MassHealth dental coverage. Bill member's private health insurance first. For information on dental services and claims, call Doral at 1-800-207-5019. 943-949 657 Member is covered for seasonal and H1N1 flu administration. 985 658 Effective July 1, 2010, global delivery codes for HSP members must be billed to MassHealth. For more information, call 1-800-841-2900. 986 661 Health New England member. For medical services, call 1-800-786-9999. For behavioral health services, call 1-800-495-0086. 987 662 Health New England member. For dental services, call 1-800-786-9999. For vision services, call 1-800-786-9999 1119 663 Member is enrolled in BH managed care and has TPL or Medicare or is in an aid category excluded from enrollment in an MCO or the PCC Plan. MassHealth is the payer of last resort. For behavioral health services authorization, call 1-800-495-0086. 1120 664 Member is enrolled in BH managed care and has TPL or Medicare or is in an aid category excluded from enrollment in an MCO or the PCC Plan. MassHealth is the payer of last resort. For behavioral health services authorization, call 1-800-495-0086. 667 One Care. Commonwealth Care Alliance member. For medical, behavioral health, and long-term services and support services, call 1-866-610-2273. 668 One Care. Fallon Total Care member. For medical, behavioral health, and long-term services and support services, call 1-855-508-4715. 669 One Care. Network Health member. For medical, behavioral health, and long-term services and support services, call 1-888-257-1985. This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix Y. EVS Codes/Messages Page Y-1 All Provider Manuals Transmittal Letter ALL-204 Date 10/01/13