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-180 July 2010 TO: All Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: All Provider Manuals (Revised Appendix Y) New Managed Care Organization Effective July 1, 2010, Health New England is a new Managed Care Organization (MCO) option for MassHealth members. The following new messages have been added to the Eligibility Verification System (EVS) to identify a MassHealth member enrolled in Health New England. Unique Message # Restrictive Message Text 661 Health New England member. For medical services, call 1-800-786-9999. For behavioral health services, call 1-800-495-0086. 662 Health New England member. For dental services, call 1-800-786-9999. For vision services, call 1-800-786-9999. Healthy Start Program Global Delivery Codes Effective for dates of service beginning July 1, 2010, the Healthy Start Program (HSP) is changing the way providers bill for and will be paid for global delivery services. The change is being made to simplify the billing of the global delivery codes for providers. Providers billing global delivery services for HSP members should submit claims only to MassHealth. HSP claims for global delivery codes should no longer be submitted to UniCare, the HSP vendor, for dates of service after July 1, 2010. Global delivery claims submitted to UniCare for dates of service on or after July 1, 2010, will be denied. The global delivery codes are 59400, 59410, 59510, 59515, 59610, 59614, 59618, and 59622. Revisions are being made to EVS messages for the impacted members as a reminder to providers about this change. The following new messages have been added to EVS. Unique Message # Restrictive Message Text 658 Effective July 1, 2010, global delivery codes for HSP members must be billed to MassHealth. For more information, call 1-800-841-2900. MassHealth Transmittal Letter ALL-180 July 2010 Page 2 The following EVS messages have been modified. Unique Message # Restrictive Message Text 602 For eligibility dates and payment under Healthy Start for outpatient, non- emergency pregnancy-related services except labor and delivery, and global delivery codes, call 1-888-488-9161. Health Safety Net Deductibles MassHealth has also updated the deductible amounts for Health Safety Net (HSN). The updated messages are as follows: Unique Message # Restrictive Message Text 645 HSN Vision and Dental Available. 659 Partial HSN Dental and Vision available. Member with 200-250 percent FPL. HSN deductible is $43. 660 Partial HSN Dental and Vision available. Member with 200-250 percent FPL. HSN deductible is $2,167. This letter transmits a revised Appendix Y. Appendix Y lists the active EVS system-generated message numbers found on the Provider Online Service Center (POSC), their corresponding unique message numbers previously used in REVS, and their respective restrictive message text. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages Y-1 through Y-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages Y-1 through Y-8 – transmitted by Transmittal Letter ALL-172 EVS 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 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 previously used in REVS, 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. The appendix also contains the MassHealth Benefit Plans Chart that lists the previous REVS coverage types, and the corresponding EVS benefit plan codes, along with descriptions and additional comments. 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 1-888-566-0008. For behavioral health services, call 1-866-444-5155. 12 31 Prior auth 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 at 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. 17, 734-739 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 1 pharmacy. For information, member may call 1-800-841-2900, 8AM-5PM 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 certain community long-term-care services (nursing, home health aide, PCA, therapies, DME, and medical supplies). Call 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 MassHealth copay on non-pharmacy 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 MassHealth copay on pharmacy services under 130 CMR 450.130(D). 271 271 Met cap on non-pharmacy 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 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. Not eligible for MassHealth. 29-32 495 Eligible for Premium Assistance. Bill member's private health insurance. 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 the Partnership at 1-800-495-0086. 530 530 No PCC/MCO authorizations needed. For MH/SA service authorization, call the Partnership at 1-800-495-0086. 550 550 Retro HSN available. 551 551 Retro Partial HSN available. HSN deductible is $XX.XX. 596 596 Essential unenrolled. Member 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 Basic unenrolled. 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 under Healthy Start for outpatient, non-emergency pregnancy-related services except labor and delivery, and global delivery codes, 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 Reimbursement from the Health Safety Net not allowable for this patient. 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, 950- 977, 980-984 611 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 Plan member. For medical services, call 1-888- 566-0008. For behavioral health services, call 1-866-444-5155. 616 616 Network Health member. For dental services, call 1-888-257-1985. For vision services, call 1-888-257-1985. 617 617 NHP member. NHP member. For dental services, call 1-800-685-9971. For vision services, call 1-800-638-3120. 618 618 BMC Healthnet Plan member. For dental services, call 1-800-207-8147. For vision services, call 1-800-877-7195. 619 619 Fallon Community Health Plan member. For dental services, call 1- 866-275-3247. For vision services, call 1-866-275-3247. 621 621 Member has future Commonwealth Care enrollment. Effective date will be first day of upcoming calendar month. Providers call 1-800 841-2900 for more information. 622 622 Network Health Member. For vision services, call 1-888-257-1985. 623 623 NHP member. For vision services, call 1-800-638-3120. 624 624 BMC Healthnet Plan member. For vision services, call 1-800-877-7195. 625 625 Fallon Community Health Plan member. For vision services, call 1-866-275-3247. 628 628 Commonwealth Care Plan Type I. Member does not have to pay a monthly premium. Member must pay copayments for prescription drugs. 629 629 Commonwealth Care Plan Type II. Member may have to pay a monthly premium. Member must pay co-payments for some services. 630 630 Commonwealth Care Plan Type II. Member must pay a monthly premium and copayments for some services. 631 631 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. 633 633 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. 634 634 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 REQS. 791-792 637 Member is HSN Secondary. Bill member’s private health insurance. See 114.6 CMR 13.00 for info on TPL REQS. 638 638 Partial HSN available. Member with 200-250 percent FPL. HSN deductible is $43. 639 639 Partial HSN available. Member with 250-300 percent FPL. HSN deductible is $2,167. 640 640 HSN not available. 641 641 Partial HSN available. 642 642 Partial HSN Dental available. Member with 200-250 percent FPL. HSN deductible is $43. 643 643 Partial HSN Dental available. Member with 250-300 percent FPL. HSN deductible is $2,167. 644 644 HSN Dental available. TBD 645 HSN Vision and Dental Available. TBD 658 Effective July 1, 2010, global delivery codes for HSP members must be billed to MassHealth. For more information, call 1-800- 841-2900. TBD 659 Partial HSN Dental and Vision available. Member with 200-250 percent FPL. HSN deductible is $43. TBD 660 Partial HSN Dental and Vision available. Member with 200-250 percent FPL. HSN deductible is $2,167. TBD 661 Health New England member. For medical services, call 1-800- 786-9999. For behavioral health services, call 1-800-495-0086. TBD 662 Health New England member. For dental services, call 1-800-786- 9999. For vision services, call 1-800-786-9999. 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 has temporary eligibility. 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. 922-928 654 Commonwealth Care Bridge member. Note that benefit and Health Safety Net information may not be applicable. For questions call 1-800-841-2900. 929-935 655 Commonwealth Care Bridge member. Note that plan type and copay messages are not applicable. For questions 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. MassHealth Benefit Plans Chart The MassHealth Benefit PlansChart lists the previous REVS coverage types and the corresponding EVS benefit plan codes, along with description and additional comments. REVS Coverage Type EVS Benefit Plan Code/Description Additional Comments BASIC HSN BASM – BASIC MANAGED CARE Requires managed care enrollment for services. Any HSN coverage will be indicated by restrictive message 597 BASIC BASM – BASIC MANAGED CARE BASF – BASIC FEE-FOR-SERVICE See above. No managed care enrollment required. BASIC/UNENROLL BASM – BASIC MANAGED CARE - BUY IN PRA – PREMIUM ASSISTANCE (NO DIRECT COVERAGE) - CMSP ONLY CMSP – CHILDRENS MEDICAL SECURITY PLAN - COMMCARE/HSN CCARE – COMMONWEALTH CARE - COMMCARE/PARTL CCARE – COMMONWEALTH CARE - COMMCARE/UNENRL CCARE – COMMONWEALTH CARE - COMMONHEALTH COM – MASSHEALTH COMMONHEALTH - COMMONWLTH CARE CCARE – COMMONWEALTH CARE CCRLM – COMMONWEALTH CARE WITH LIMITED - EAEDC EAEDC – EMERG AID TO ELDERLY DISABLED AND CHILDR - ESSENTIAL HSN ESSM – ESSENTIAL MANAGED CARE Requires managed care enrollment for services. Any HSN coverage will be indicated by restrictive message 596. ESSENTIAL ESSM – ESSENTIAL MANAGED CARE ESSF – ESSENTIAL FEE-FOR-SERVICE See above. No managed care enrollment required. ESSNTL AND LMTD BASM – BASIC MANAGED CARE LIM – LIMITED - ESSNTL/UNENROLL ESSM – ESSENTIAL MANAGED CARE - FAMILY ASSIST FADC – MASSHEALTH FAMILY ASSISTANCE - HLTH SAFETY NET HSN – HEALTH SAFETY NET - HSN PARTIAL PHSN – PARTIAL HEALTH SAFETY NET - LIMITED LIM – MASSHEALTH LIMITED CCRLM – COMMONWEALTH CARE WITH LIMITED - LMTD CMSP LIMCP – LIMITED PLUS CMSP - LMTD HLTHY STRT LIMHS – LIMITED PLUS HEALTHY START - MH ONLY DMH – DMH ONLY - PREMIUM ASSIST PRA – PREMIUM ASSISTANCE (NO DIRECT COVERAGE) FAPAE – EXPANSION FAM ASSIST PREM ASSIST PLUS - PRENATAL PRN – MASSHEALTH PRENATAL - RETRO HSN This information is being conveyed via restrictive message 550. - RETRO PARTL HSN This information is being conveyed via restrictive message 551. - SENIOR BUY IN SBI – SENIOR BUYIN - SENIOR PHARMACY SPH – SENIOR PHARMACY - STANDARD STD - MASSHEALTH STANDARD HCBSD – STANDARD PLUS MR/DD HOME & COMMUNITY BASED SERVICES WAIVER HCBSM – STANDARD PLUS MRC/TBI HOME & COMMUNITY BASED SERVICES WAIVER HCBSE– STANDARD PLUS FRAIL ELDERS HOME AND COMMUNITY BASED SERVICES WAIVER -