DPW provides the Eligibility Verification System (EVS) for medical providers and authorized non-medical providers to verify recipient eligibility for MA benefits and information for billing purposes. The EVS is an on-line system that offers MA providers the information to make an informed decision prior to rendering a service or item.
In lieu of updating or replacing the swipe boxes previously offered by EDS, OMAP and EDS are providing Provider Electronic Solution software free-of-charge for download from the OMAP website.
The following methods are used to access EVS:
Web Interactive.
EVS Software.
POS Card Swipe Devices.
Mainframe.
Batch EVS.
Touchtone telephone or rotary phone with a tone generator pad.
The key elements to access EVS are:
MA provider number.
A unique 13 digit number (nine digit provider number plus 4 digit service location) assigned by the Department. Non-medical providers such as the Medical Assistance Transportation Providers (MATP) are also assigned numbers.
Current ACCESS card;
Recipient Number.
CIS Recipient number (9 digits) and validation number (1 digit).
ACCESS Card Issue Number.
2 digit number.
Date of Service.
When a provider does not indicate a date of service, EVS defaults to current date. EVS can verify eligibility for the current date or for dates of service 365 days prior to the current date.
Important: When a recipient does not present an ACCESS card, providers will use the following methods to access EVS:
Recipient Social Security Number and Date of Birth.
Recipient Name and Date of Birth.
When CIS is updated, the information is immediately available to providers.
An eligible response does not mean that the Department will pay for medical services. The information provided should be used to determine the scope of medical coverage.
EVS provides the following information:
Date of Service.
EVS can verify recipient eligibility for previous 365 days. When a provider does not indicate a date of service, EVS displays recipient eligibility information for current (day of inquiry) date. Effective September 3, 2005 at midnight, the Eligibility Verification System (EVS) will be returning a “6” meaning “Inactive” in place of an “I” which means “Non-Covered in the EB01 element in the EB Segment in Loop 2110C of the 271 response if the recipient is found on our system but not eligible during the dates of service returned.
Recipient number (CIS Recipient Number).
Recipient Name (not on phone).
Recipient date of birth.
The name, date of birth and sex can be used to confirm recipient identity
Recipient sex.
Health Care Benefits Package Number.
The HealthCare Benefits Package (HCBP) defines MA coverage. The HCBP is determined from the information on CIS, age and the CIS TPL.
Category of Assistance.
Program Status Code.
Effective July 1, 2007, number of visits remaining based on paid claims status.
EVS provides additional information if the recipient is enrolled in a managed care plan, has third party resources, or is in the Recipient Restriction (Lock-In) Program.
Managed Care Plan (MCP).
If a recipient is enrolled in an MCO, EVS provides the name and phone number of the plan and the name and phone number of the primary care provider (if available). Because a recipient’s managed care coverage may continue beyond their MA eligibility period, EVS will inform the provider that a recipient may be eligible for benefits through a managed care plan on the date of service, but NOT eligible for MA.
ACCESS Plus (AP).
EVS provides the name and phone number of the primary care case manager (PCCM) (if available).
Recipient Restriction.
EVS gives the provider type. For POS and PC responses, EVS gives both the provider type and provider name. The following message will precede the restriction lock-in information. Message: Services may be rendered only by the designated lock-in providers blow. Practitioner specialty services or referrals require a Restricted Recipient Referral Form (MA 45) to be presented prior to services, or condition requires emergency treatment.
Inpatient Pay.
Inpatient patient pay applies only to provider types 11 (General Hospital), 12 (Rehabilitation Hospital, Unit or D&A Hospital or Unit) and 13 (Private Psychiatric Hospital or Psychiatric Unit). EVS responds with a message when patient pay is due.
Third Party Resource
EVS responds with third party resource information that provides coverage for the provider type submitting the inquiry. The company name, type of coverage and policy or group number will be returned for up to three resources. EVS displays information that is on the CIS TPL.
Medicare Part B Crossover Information
The following message will be displayed for those budgets that the Department will only pay up to the MA fee. Message: Recipient is eligible for Medicare Part B deductible and coinsurance payments ONLY up to the MA fee.
EVS Ineligible Response
EVS will return an ineligible response if either the recipient or the provider is not eligible on the date of service. When EVS returns an ineligible response, the original information submitted is returned. This information should be reviewed to determine if it was submitted correctly.
EVS responds with a special error message if an invalid ACCESS card issue number. Message: ACCESS Card invalid. Social Security Number or date of birth do not match CIS information, a Recipient Ineligible response will be returned.
|
1. |
Message Error |
Provider is not on file. The provider number submitted is not a valid number. |
|
2. |
Message Error |
Provider is not eligible on DOS. The provider is not eligible to render MA services on the date of service. |
|
3. |
Message Error |
Recipient is ineligible. The recipient is not eligible on the date of service, or the recipient information submitted is incorrect or invalid. |
|
4. |
Message Error |
The ACCESS card is invalid The card issue number submitted is not valid or current for the recipient. |
|
5. |
Message Error |
Line unavailable (point of sale device only). There is no dial tone. Check the phone line connected to the device. |
|
6. |
Message Error |
TXN Error ## (point of sale device only). This is a telecommunications error. Please try again later. |
|
7. |
Message Error |
System experiencing difficulties. Please try later. EVS is temporarily unavailable. |
Important: CAOs cannot resolve provider concerns. EVS has coded edits that CAOs cannot resolve.
When the Helpline cannot resolve the problem, take the following steps:
Check CIS screens to determine that the current ACCESS card is being used. Check the Card Issue Number. EVS provides information ONLY on current valid cards.
Check CIS TPL. EVS uses information from the CIS TPL; not the MA resource indicator on CIS. Correct information on CIS TPL.
If all information is correct, refer the problem to the CIS Hotline. The following information is needed for problem resolutions:
Provider name and identification number.
Phone number and contact name.
Date of Service.
Error code number if on-line billing problem from pharmacist.
10 digit recipient number (CIS Recipient Number with verification digit).
Card Issue Number used to access EVS.
Name of recipient, social security number, date of birth.
The following helplines are available to answer providers concerns regarding EVS:
PROMISe Provider Inquiry. See Appendix J.
The PROMISe Provider Inquiry supports the following areas:
Instructions for using EVS via touch-tone telephone;
Additional information regarding CIS TPL;
Additional information regarding Recipient Restriction; and
Clarification of EVS responses from all access methods.
NOTE: Refer providers to this hotline when they have questions regarding recipient eligibility, not recipients.
EDS Provider Assistance Center. See Appendix J.
The Provider Assistance Center supports the following areas:
Software for PC and Points of Sale (POS) applications;
Hardware, including the POS Device with regards to repair and replacement of broken units; and
Ordering of POS Devices and PC software.
Updated September 9, 2014, Replacing February 14, 2012