Eligibility Verification System Overview

The Eligibility Verification System (EVS) provides important benefit information about MassHealth members. Providers must check EVS before providing services to MassHealth members.

The Eligibility Verification System is available through the Provider Online Service Center (POSC). EVS provides easy access to current and complete member eligibility information on the date services are provided or within a specific date range. EVS is available 24 hours a day, seven days a week.

Important: If you do not verify a member's eligibility before providing services, you might not be paid for those services.

Eligibility verifications through the POSC can be performed via Direct Data Entry (DDE) for a single member verification or via Batch for checking multiple member verifications at the same time.

Submitting Batch Transactions

MassHealth providers and vendors submitting transactions in conformance with Phase I CORE 155: Eligibility and Benefits Batch Response Time Rules, and in accordance with HIPAA ASC X12 and MassHealth policy, must follow these submission guidelines to ensure timely and efficient processing of transactions.

1.  ONLY check eligibility for those MassHealth members you will actually provide services to on that day or the following day.

2.  DO NOT submit your entire roster of MassHealth members unless you are providing services for your entire roster of members the same day or the following day.

3.  DO NOT include more than 3,000 member requests in any single ST/SE segment within an eligibility batch file request. ST/SE segments that exceed this maximum number of members will be rejected.

4.  YOU MUST INCLUDE a valid member Medicaid Identification (MID) Number on the eligibility request, if known. Invalid Medicaid Identification Numbers will be rejected. If the Members Medicaid Identification Number is not known, you must include the following four demographic data elements so that the system may search for the member. If a single match is found, eligibility information will be returned:

• First name
• Last name
• Date of birth
• Gender

5.  WHEN an eligibility request returns a valid MID based solely upon the demographic data submitted in the 270, YOU MUST ensure you populate all subsequent eligibility requests for that member with the correct MID

It is important that you follow these file submission guidelines to ensure a timely response to your file submission.

To request a copy of any of the MassHealth Companion Guides, or if you have any questions, please contact MassHealth Customer Service at [phone].