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-167 May 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Revised Appendix Y) This transmittal letter issues revised Appendix Y. Appendix Y now lists the active Eligibility Verification System (EVS) system-generated message numbers on the Provider Online Service Center (POSC), their corresponding unique message numbers previously used in REVS, and their respective restrictive message text. Providers accessing EVS through the POSC to verify a patient's eligibility before providing medical services will receive one or more of these following restriction messages. The appendix also includes the EVS benefit plans associated with the coverage types that were previously displayed in REVS. Before providing services providers will need to review what services are covered under each benefit plan at our Web site at www.mass.gov/masshealth or call MassHealth Customer Service at 1-800-841-2900. Effective May 23, 2009, the associated numbers for all of the restrictive messages displayed in EVS will be updated. Here is an example of how this new restrictive message display will look to providers on the POSC: 76/525 For mental health or substance abuse service authorization, call the Partnership at 1-800-495-0086. Please note that in some cases there may be multiple EVS system-generated message numbers for one unique message number (previously used in REVS). The reason you see multiple message numbers is due to a system design for NewMMIS that allows us to update these messages in a more flexible and timely manner. In most cases the messages have remained the same. However there are some message changes that you need to be aware of, which are described below. For Commonwealth Care, EVS will now display the following message when a member has selected a Commonwealth Care managed care organization but the coverage is not yet effective. Unique Message # Restrictive Message Text 621 Member has future Commonwealth Care enrollment. Effective date will be first day of upcoming calendar month. Providers can call 1-800-841-2900 for more information. MassHealth has also updated the deductible amounts for HSN. The updated messages are as follows: Unique Message # Restrictive Message Text 638 Partial HSN Available. Member with 200-250 Percent FPL. HSN deductible is $43. 639 Partial HSN Available. Member with 250-300 Percent FPL. HSN deductible is $2,167. 641 Partial HSN Available 642 PARTIAL HSN DENTAL AVAILABLE. MEMBER WITH 200-250 PERCENT FPL. HSN DEDUCTIBLE IS $43. 643 PARTIAL HSN DENTAL AVAILABLE. MEMBER WITH 250-300 PERCENT FPL. HSN DEDUCTIBLE IS $2,167. Please note that unique message 075 is not used in NewMMIS. All members in NewMMIS will have a unique ID that will not be shared with any other individual. MEMBER ID MAY HAVE BEEN USED IN THE PAST BY MORE THAN ONE MASSHEALTH MEMBER. VERIFY MEMBER NAME AND BIRTHDATE ON RESPONSE. 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-6 — transmitted by Transmittal Letter ALL-162 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 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- Unique 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 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, 735, 736, 737, 738, 739 56 Network Health member. For medical services call 1-888-257-1985. For behavioral health services call 1-888-257-1986. 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. 96 96 Care Management Pilot Program member. Please call 413-794-9428 to coordinate all medical and behavioral health services. 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 member. Prior authorization now required for home health (PDN, Nursing, HH Aide, PCW) info 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). 22-25, 63, 64, 92-95, 97-105, 703, 281 281 Health Safety Net is for certain hospital and CHC services ONLY. For more information, Call 1-877-910-2100. 26, 27, 299-364, 367-450 306 Individual has submitted an MBR and is NOT ELIGIBLE for MassHealth. For more information, call 1-800-841-2900. 740-746 311 Fallon member. For medical services call 1-800-868-5200. For behavioral health services CALL 1-888-421-8861. 366 366 Met cap on pharmacy services under 130 CMR 450.130(C). 825-829 831-841 386 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 only for copays and deductibles for well-child visits. 74 490 DMH Client. Not eligible for MassHealth. 29-32 495 Eligible for Premium Assistance only. Bill member's private health insurance. 500, 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 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 or Retro Partial HSN available. 595, 762 595 Eligible but not enrolled in managed care. Service cannot be billed to MassHealth. Member must enroll. HSN available. 596 596 ESSENTIAL UNENROLLED. Member also eligible for Essential. Member must enroll in managed care to receive these benefits. Member must call 1-800-841-2900 597 597 BASIC UNENROLLED. Member also eligible for Basic. Member must enroll in managed care to receive these benefits. Member must call 1-800-841-2900. 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 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, 766 611 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 1-800-341-8478. For Vision Services call 1-888-257-1985 617 617 NHP member. For dental services call 1-800-341-8478. For vision services call 1-800-638-3120. 618 618 BMC Healthnet Plan member. For Dental Services call 1-800-685-9971. For vision services call 1-800-615-1883. 619 619 Fallon Community Health Plan member. For Dental Services call 1-800-822-5353. For vision services call 1-800-868-5200 85-87, 704-709 620 Member also eligible for Commonwealth Care. Member must enroll in Managed Care to receive these benefits. Call 1-877-MA-ENROLL 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 1-800-615-1883. 625 625 Fallon Community Health Plan member. For vision services call 1-800-868-5200. 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. 853-913 636 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. 89, 771-772 NHP member. For vision services call 1-800-462-5449. 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. 645 645 Partial HSN Dental available. 770, 915 647 HSN pharmacy copays may be applicable. MassHealth Benefit Plans Chart The MassHealth Benefits Plan Chart 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 in a restrictive message. 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 SERVICE 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 in a restrictive message. ESSENTIAL ESSM - ESSENTIAL MANAGED CARE ESSF - ESSENTIAL FEE-FOR-SERVICE See above. No managed care enrollment required. MassHealth Benefit Plans Chart (cont.) REVS Coverage Type EVS Benefit Plan Code/Description Additional Comments 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 550. - SENIOR BUY IN SBI - SENIOR BUYIN - SENIOR PHARMACY SPH - SENIOR PHARMACY - STANDARD STD - MASSHEALTH STANDARD HCBSD - MR/DD HOME & COMMUNITY BASED SERVICES WAIVER HCBSM - MRC/TBI HOME & COMMUNITY BASED SERVICES WAIVER - This page is reserved.