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-135 October 2005 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: 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. Four new REVS codes (075, 595, 596, and 597) and their descriptions have been added to Appendix Y. In addition, phone numbers listed in three other codes have been changed. Provider Manual Appendices on MassHealth Web Site Effective 12/1/04, MassHealth no longer mails updates to providers for 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." A large majority of surveyed providers expressed an interest in getting an automatic e-mail alert from MassHealth to notify them about changes in MassHealth policies and procedures. So now you can go to our Web site and sign up for these e-mail alerts. However, please note that for now you will still receive a postcard, even if you sign up for e-mail alerts. To sign up for e-mail notifications about MassHealth provider publications, go to www.mass.gov/masshealthpubs and click on the sign-up link under "Provider Library." 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 9118 Hingham, MA 02043 Fax: 617-988-8974 If you have any questions about the information in this transmittal letter, please call MassHealth Customer Service at 1-800-841-2900. 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-129 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 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 1-800-462-5449. 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 1-888-566-0008. 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. 035 MASSHEALTH/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 1-888-566-0008. 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. 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 BIRTH DATE 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. 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. 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 1-800-841-2900. 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 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. Code Message 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 606 REIMBURSEMENT FROM THE UNCOMPENSATED CARE POOL NOT ALLOWABLE FOR THIS PATIENT. FOR INFORMATION CALL 617-988-3222 OR 1-877-910-2100