All eligible recipients (including those recipients enrolled in a managed care organization [MCO]) will have a permanent identification card that identifies their eligibility for covered MA services. However, you should not assume that a patient is eligible whether they are able to present a valid identification card or not. It is vital that you verify the recipient's eligibility through the Eligibility Verification System (EVS) each time the recipient is seen. EVS should be accessed on the date the service is provided since the recipient's eligibility is subject to change. Payment will not be made for ineligible recipients.
The purpose of EVS is to provide the most current information available regarding a recipient's MA eligibility and scope of coverage. EVS will also provide details on the recipient's third-party resources and managed care plan when applicable.
Providers can access EVS through the PROMISe™ Provider portal, or through their own certified software. If those methods are not available, they can access the EVS through the Automated Voice Response System by calling 1-800-766-5387 and entering the recipient's social security number and date of birth.
The information returned from EVS is consistent across all methods of submission; however, depending upon the information submitted on the inquiry, the results may be different. For example, if you perform an inquiry using the 10-digit recipient ID number and the two-digit card issue number, and either one of those data elements is incorrect (most likely the card issue number, as you must use the most current card issue number), you will receive an ineligible response. If, however, you use the recipient's social security number and date of birth, you may receive an eligible response because both of these elements are most likely accurate. It is important to verify and submit accurate recipient information when checking eligibility via the EVS.
The dial-up (modem) Bulletin Board System (BBS) solution for electronic file management was decommissioned at the end of May 2011. EVS will accept and return the standardized electronic transaction formats for eligibility requests and responses as mandated by the Health Insurance Portability and Accountability Act (HIPAA). The eligibility request format is called the HIPAA 270 Health Care Eligibility Benefit Inquiry format (also known as 270 Eligibility Inquiry). The eligibility response format is called the HIPAA 271 Health Care Eligibility Benefit Response (also known as 271 Eligibility Response). Both formats may also be referenced by the 3-digit transaction number, 270 and 271. Providers and other approved agencies that submit electronic requests in the 270 format will receive an EVS response with eligibility information in the 271 format.
There are several types of Pennsylvania ACCESS cards providers may encounter. Recipients who are eligible for medical benefits only will receive the yellow ACCESS card. Recipient information is listed on the front of the card and includes the full name of the recipient, a 10-digit recipient number, and a 2-digit card issue number.
The Electronic Benefits Transfer (EBT) card can now have two faces, both of which are valid. The original EBT ACCESS card is blue and green in color with the word "ACCESS" printed in yellow letters. Recipient information is listed on the front of the card and includes the full name of the recipient, a six-digit bank code number followed by a 10-digit recipient number, then a two-digit card issue number, and a bank verification number. In addition, the newly redesigned EBT card has entered into circulation. This redesigned card has a background photo of the PA State Capitol building framed by cherry blossom branches. On this version of the card, the client's full name and card number are on the bottom left, while the top left corner has a keystone and 'Pennsylvania', and the upper right-hand corner has the letters 'EBT'. The EBT card is issued to MA recipients who receive cash assistance and/or food stamps as well as medical services, if eligible.
When a Pennsylvania ACCESS card is lost or stolen, the recipient should contact his/her County Assistance Office (CAO) caseworker to request a replacement card. The card issue number is voided to prevent misuse when the new card is issued. A replacement card should be received in a maximum of seven days. If a card is needed immediately, an interim paper card can be issued by the CAO. This ensures recipients of uninterrupted medical services. The interim card contains the same Recipient Number and Card Issue Number as the previous ACCESS card.
EVS does not provide eligibility information when a provider attempts to verify eligibility using a lost or stolen ACCESS card. EVS will return the response "The ACCESS card is invalid". If the old card is found or returned after a new card is obtained, the old card should be destroyed by the recipient, as it is no longer usable.
The recipient is not MA eligible if they only have EPOMS. The MHX category is only used for tracking mental health service encounter claims for County Mental Health Funded Base Programs. In the event that a recipient is eligible for health benefits associated with other programs, the recipient will be authorized for those services under a separate healthcare benefits package.
The Eligibility Verification System (EVS) has been enhanced to inform providers when a recipient has exceeded the 18 visit limit. If not, EVS indicates the number of countable office visits, clinic and home visits remaining within the scope of benefits for adult MA and adult GA recipients. This is pursuant to the 18 visit limit, during the July 1 through June 30 state fiscal year service period. EVS will provide timely validation of the number of countable visits remaining based on actual claims paid at the time of the inquiry.
For additional information, please refer to Medical Assistance Bulletin 99-07-10 or the 18-visit limit procedure code chart which can be found on the department's website at 18 Visit Limit Chart
HCB 15 is SelectPlan for Women. This program provides coverage of selected family planning services, pharmaceuticals, and devices for women who are not otherwise eligible for MA. Prior to performing services, you should review the MA Bulletins related to SelectPlan
Prior to performing services, you should review the MA Bulletins related to SelectPlan.