1. How can I determine if a recipient is eligible for Medical Assistance (MA)/Medicaid if they do not have their ACCESS Card?
RESPONSE: All eligible recipients (including those recipients enrolled in a MCO) will have a permanent plastic 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.
2. Sometimes when I check a patient’s eligibility on EVS using their recipient ID number, the coverage shows as not effective. If I check the same patient’s eligibility using their name and date of birth, coverage shows as effective. Why does this happen?
RESPONSE: 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.
3. We are having difficulty reading the EVS printout. Is there a manual available on how to read the printout and actually use it via modem submission?
RESPONSE: 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.
4. How many types of Medical Assistance cards are there and what is the difference between them?
RESPONSE: There are two 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) ACCESS card is blue and green in color with the word “ACCESS” printed in yellow letters. This card is issued to MA recipients who receive cash assistance and/or food stamps as well as medical services, if eligible. 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.
5. What happens if a recipient loses his/her ID card?
RESPONSE: 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.
6. What if the EVS response displays that a recipient only has service program category MHX and service program EPOMS?
RESPONSE: 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 benefit package.
7. How can I determine if the recipient has exceeded their 18 office visits for the fiscal year?
RESPONSE: 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.
8. The recipient is showing eligible for Healthcare Benefit package (HCB) 15, what services are they covered for?
RESPONSE: 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 at the following URL:
Use the Subject Search: “SelectPlan for Women” to find related MA Bulletins.
To view the complete Healthcare Benefits Packages Reference Chart, click the link below: