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Provider Handbook: Providers and Members

This is part of the MassHealth Provider Handbook

A MassHealth member is a person MassHealth has deemed eligible and has enrolled in health coverage.

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Member Coverage Types

A coverage type is a scope of medical services, other benefits, or both that are available to members who meet specific eligibility criteria. A member is eligible for services and benefits according to their coverage type. 

Each coverage type has a list of services that its MassHealth members can receive. Payment for the covered services listed in 130 CMR 450.105 is subject to all MassHealth conditions and restrictions, including all applicable prerequisites for payment. Providers should refer to their program manual for a full list of services, restrictions, and conditions, as well as reviewing the online chart of MassHealth covered services.

Checking a Member’s Eligibility

Regulations require providers to check eligibility before providing services to a member. Fee-for-service providers can use the Provider Online Service Center to check the Eligibility Verification System (EVS) via direct data entry single-check or batch (multiple member checks simultaneously). EVS messages tell providers the type of health plan in which a member is enrolled, if any, and whom to contact with billing questions.

EVS

The MassHealth EVS is designed to display the status of a member’s health care coverage for any dates of service requested (though it does not display eligibility for future dates). This includes the identification of the health plan and the type of plan a member has, if applicable, and is based on the information MassHealth has processed as of the date of the EVS access. For members who have other health care coverage in addition to MassHealth, EVS will display information about existing third-party payers, including the following:

  • the third-party carrier’s name(s) and plan details 
  • 7-digit MassHealth proprietary carrier code

For more information about checking member eligibility, please refer to the following web pages:

Mass.gov webpage titled "Eligibility Verification for MassHealth Providers"

The EVS tool is for fee-for-service providers; other providers (such as ordering, referring, and prescribing providers and managed care entity providers) cannot access it. Learn more about EVS codes and messages in Appendix Y of MassHealth’s All Provider Manual. 

Provider Requirements to Verify Eligibility and Obtain Payment from Primary Payer

MassHealth regulations at 130 CMR 450.316 require providers to make diligent efforts to identify and obtain payment first from other resources, including casualty payer payments, to ensure that MassHealth is always the payer of last resort. Conduct the following steps before providing care.

  1. Determine the existence of health insurance by asking the member if they have other insurance and by using insurance databases available to the provider.
  2. Verify the member’s other health insurance coverage currently known to MassHealth through EVS on each date of service and at the time of billing.
Date published: July 29, 2022
Last updated: August 21, 2026

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