CHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION …

1 CHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION TO ACCESS EVS Web Interactive: A web ELIGIBILITY request window is available to approved providers and other agencies via the PROMISe Provider Portal. Log on at Batch Inquiry: ELIGIBILITY information can be requested by submitting batch ELIGIBILITY inquiries to the electronic bulletin board (EBS). Providers can use purchased software, certifi ed in-house software, or the PROMISe Provider Electronic Solutions (PES) software. More information and certifi cation information can be found at VAN: Value Added Network (VAN) vendors collect requests for ELIGIBILITY information in a real-time interactive processing mode and interface with the PROMISe EVS system. Providers will need to contract directly with an approved VAN submitter to use this access method. Telephone: The Automated Voice Response System (AVRS) accepts requests for and returns ELIGIBILITY information over a toll-free phone number.

2 Using a touch-tone phone, please call ELIGIBILITYThe PROMISe ELIGIBILITY Verifi cation System (EVS) enables you to determine a PARTICIPANT s Medical Assistance ELIGIBILITY , as well as the PARTICIPANT s scope of coverage. Do not assume that a PARTICIPANT is eligible for Medical Assistance because he/she has an ACCESS or CHC health plan ID card. A PARTICIPANT s ELIGIBILITY is subject to change; therefore, it is vital to check EVS to verify a recipient s ELIGIBILITY each time services are provided. The information in EVS is refl ective of the current information that the state has available. At times, resources become known retrospectively at which point a post-payment recovery may be initiated by the managed care organization (MCO), as Medicaid is always the payor of last resort. It is important to always ask participants if they have additional HEALTHCHOICES WILL NOT CHANGE A PARTICIPANT S MEDICARE COVERAGEEVS EXAMPLE #1 This PARTICIPANT is in a nursing facility and eligible under the long-term care Medical Assistance category.

3 He is in Community HealthChoices, Behavioral HealthChoices, and receives Medicare. Currently, he is in a penalty period for their nursing facility :DOE, JOHNR ecipient ID:4103536639 Date of Birth:01/04/1941 Gender:MaleRecipientStatus:Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Plan02/01/2018 Benefi t Related En ty:Managed Care Organiza onBHDA-DAUPHIN COUNTY - CBHNPI nforma on ContactTelephone: (888)722-8646 ELIGIBILITY DetailTypeNameBEGINENDM anaged CareBHDA-DAUPHIN COUNTY CBHNP02/01/201802/01/2018 MedicaidCategory: PANP rogram Status: 00 Service Program: HCB50-ADULT02/01/201802/01/2018 Managed CareCH2A-AMERIHEALTHCARITAS PA COMMUNITY HEALTHCHOICES02/01/201802/01/2018 Other or Addi onal PayorMEDICARE PART B02/01/201802/01/2018 Other or Addi onal PayorMEDICARE PART A02/01/201802/01/2018 Other or Addi onal PayorTRANSFER PENALTY02/01/201802/01/2018 ELIGIBILITY SummaryBHDA-DAUPHIN COUNTY CBHNPCH2A-AMERIHEALTHCARITAS PA COMMUNITY HEALTHCHOICESTRANSFER PENALTYC ategory: PANP rogram Status: 00 Service Program: HCB50-ADULTMEDICARE PART BMEDICARE PART A02/01/201802/01/201802/01/201802/01/201 802/01/201802/01/201802/01/201802/01/201 802/01/201802/01/2018 BEHAVIORAL HEALTHCHOICESCHC HEALTH PLANPENALTY PERIODADULT BENEFITS PACKAGETHIRD PARTY LIABILITYCHECKING ELIGIBILITYCHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSUNDERSTANDING THE ELIGIBILITY VERIFICATION SYSTEM EVS EVS methods, inquiries, and response formats will not change with the Community HealthChoices implementation.

4 EVS return codes for Community HealthChoices managed care plans are:Southwest CH2A AmeriHealth Caritas Pennsylvania CH2B PA Health & Wellness CH2C UPMC Community HealthChoicesSoutheast CH2D Keystone First Community HealthChoices CH2E PA Health & Wellness CH2F UPMC Community HealthChoicesEVS EXAMPLE #1 continuedStatus:MedicaidService Type:1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareInsurance Type:MC-MedicaidCoverage Descrip on:Category: PANP rogram Status: 00 Service Program: HCB50-ADULTPlan02/01/2018 Benefi t Related En ty:PayerMA Service ProgramInforma on Contact Telephone: (800)537-8862 Status:Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Plan02/01/2018 Benefi t Related En ty:Managed Care Organiza onCH2A-AMERIHEALTH CARITAS PA COMMUNITY HEALTHCHOICESI nforma on ContactTelephone: (800) 111-1111 Message TextPrimary Care Provider informa on is not on fi le for date service enteredStatus:Other or Addi onal PayorService Type:30-Health Benefi t Plan CoverageInsurance Type:MB-Medicare Part BEligibility01/05/2018 Benefi t Related En ty:PayerMEDICARE PART BPayer Iden fi er: 100 Message TextRecipient is dual eligible.

5 Payment approval is subject to MA policy, service delivery rules and DetailEligibility DetailEligibility Detail1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareMC-MedicaidCategory: PANP rogram Status: 00 Service Program: HCB50-ADULT02/01/2018 Recipient is dual eligible. Payment approval is subject to MA policy, service delivery rules and Care Organiza onCH2A-AMERIHEALTH CARITAS PA COMMUNITY HEALTHCHOICESI nforma on ContactTelephone: (800) 111-1111 Other or Addi onal Payor30-Health Benefi t Plan CoverageMB-Medicare Part B01/05/2018 PayerMEDICARE PART BPayer Iden fi er: 100 HEALTH PLAN INFORMATIONMEDICAREINFORMATIONELIGIBILIT Y DETAIL FOR ADULT BENEFIT PACKAGEELIGIBILITY DETAIL OF ADULT BENEFIT PACKAGECHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSEVS EXAMPLE #1 continuedStatus:Other or Addi onal PayorService Type:30-Health Benefi t Plan CoverageInsurance Type:MA-Medicare Part AEligibility01/05/2018 Benefi t Related En ty:PayerMEDICARE PART APayer Iden fi er: 600 Message TextRecipient is dual eligible.

6 Payment approval is subject to MA policy, service delivery rules and :Other or Addi onal PayorEligibility02/01/2018 Benefi t Related En ty:PayerTRANSFER PENALTYP ayer Iden fi er: 903 Message TextThe department will deny claims for LTC services in the community or in an ins tu onal se ng which are provided during the penalty DetailEligibility DetailOther or Addi onal Payor30-Health Benefi t Plan CoverageMA-Medicare Part A01/05/2018 PayerMEDICARE PART APayer Iden fi er: 600 Recipient is dual eligible. Payment approval is subject to MA policy, service delivery rules and INFORMATIONThe department will deny claims for LTC services in the community or in an ins tu onal se ng which are provided during the penalty PERIOD INFORMATIONEVS EXAMPLE #2 This individual is in the CHC home and community-based waiver. She in Community HealthChoices and Behavioral HealthChoices. Name:DOE, JANE Recipient ID:1603728138 Date of Birth:01/01/1980 Gender:FEMALER ecipientTypeNameBEGINENDM edicaidCategory: PJWP rogram Status: 00 Service Program: HCB50-ADULT01/01/201801/31/2019 Managed CareBHAL-COMMUNITY CARE BEHAVIORAL HLTH01/01/201801/31/2019 Managed CareCH2E-PA HEALTH AND WELLNESS COMMUNITY HEALTHCHOICES01/01/201801/31/2019 ELIGIBILITY SummaryBHAL-COMMUNITY CARE BEHAVIORAL HLTHCH2E-PA HEALTH AND WELLNESS COMMUNITY HEALTHCHOICESC ategory: PJWP rogram Status: 00 Service Program: HCB50-ADULT01/01/201801/31/2019 BEHAVIORAL HEALTHCHOICES01/01/2018 CHC HEALTH PLAN01/01/201801/31/2019 ADULT BENEFITS PACKAGECHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSEVS EXAMPLE #2 continuedManaged CareCategory: PJWP rogram Status: 00 Service Program: CHC20-COMMUNITY HEALTHCHOICES WAIVER01/01/201801/31/2019Co-InsurancePA Medicaid-No Co-Insurance: 0%Co-PaymentMA-Pharmacy Generic Prescrip ons/Refi lls: $ Brand Name Prescrip on/Refi lls.

7 $ ent Hospital/Rehab/Private Psych: $ c Radiology/X-ray (Tech Component): $ ent Psychotherapy Services: $ Scale: $ blePA Medcaid-No Deduc ble: $0 Limita onsPA Medicaid-Limita ons: Limita on Desk ReferenceStatus:MedicaidService Type:1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareInsurance Type:MC-MedicaidCoverage Descrip on:Category: PJWP rogram Status: 00 Service Program: HCB50-ADULTPlan01/01/2019-01/31/2019 Benefi t Related En ty:PayerMA Service ProgramInforma on Contact Telephone: (800)537-8862 ELIGIBILITY Detail1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareMC-MedicaidELIGIBILITY DETAIL OF ADULT BENEFIT PACKAGEC ategory: PJWP rogram Status: 00 Service Program: CHC20-COMMUNITY HEALTHCHOICES WAIVER01/01/2018 CHC20 COMMUNITY HEALTHCHOICES WAIVERS tatus:Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Plan01/01/2018-01/31/2018 Benefi t Related En ty:Managed Care Organiza onBHAL-COMMUNITY CARE BEHAVIORAL HLTHI nforma on ContactTelephone: (888)251-2224 ELIGIBILITY DetailCHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSEVS EXAMPLE #2 continuedCHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSS tatus.

8 Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Plan01/01/2018-01/31/2018 Benefi t Related En ty:Managed Care Organiza onCH2C-UPMC COMMUNITY HEALTHCHOICESI nforma on ContactTelephone: (888)111-1111 Message TextPrimary Care Provider informa on is not on fi le for date of service DetailHEALTH PLAN CONTACT INFORMATIONS tatus:Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Coverage Descrip onCategory: PJWP rogram Status: 00 Service Program: CHC20-COMMUNITY HEALTHCHOICES WAIVERPlan01/01/2018-01/31/2018 Benefi t Related En ty:PayerManaged Care Service ProgramEligibility DetailCHC20 COMMUNITY HEALTHCHOICES WAIVERC ategory: PJWP rogram Status: 00 Service Program: CHC20-COMMUNITY HEALTHCHOICES WAIVEREVS EXAMPLE #3 This individual is in a nursing facility and eligible under the long-term care Medical Assistance category. He is enrolled in both Community HealthChoices and Behavioral HealthChoices and also receives Medicare.

9 He has a $100 spend down :SMITH, ROBERT Recipient ID:6181224145 Date of Birth:01/01/1990 Gender:MALER ecipientEVS EXAMPLE #3 continuedCHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSTypeNameBEGINENDM edicaidCategory: JProgram Status: 37 Service Program: HCB50-ADULT01/01/201801/31/2018 Managed CareBHAL-COMMUNITY CARE BEHAVIORAL HLTH01/01/201801/31/2018 Managed CareCH2A-AMERIHEALTH CARITAS PA COMMUNITY HEALTHCHOICES01/01/201801/05/2018 Other or Addi onal PayerMEDICARE PART B01/01/201801/05/2018 Other or Addi onal PayerMEDICARE PART A01/01/201801/05/2018 Spend DownMonth: $ Medicaid-No Co-Insurance: 0%Deduc lbePA Medicaid-Deduc ble: $0Co-PaymentPA Medicaid-No Co-Payment: $0 Limita onsPA Medicaid-Limita ons: Limita on Desk ReferenceEligibility SummaryBHAL-COMMUNITY CARE BEHAVIORAL HLTHCH2A-AMERIHEALTH CARITAS PA COMMUNITY HEALTHCHOICESC ategory: JProgram Status: 37 Service Program: HCB50-ADULT01/01/201801/31/2018 BEHAVIORAL HEALTHCHOICES01/01/2018 CHC HEALTH PLAN01/01/201801/31/2018 ADULT BENEFITS PACKAGEMEDICARE PART BMEDICARE PART A01/01/201801/05/201801/01/201801/05/201 8 THIRD PARTY LIABILITYM onth: $ DOWNS tatus:MedicaidService Type:1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareInsurance Type:MC-MedicaidCoverage Descrip on:Category: JProgram Status: 37 Service Program: HCB50-ADULTPlan1/19/19 Benefi t Related En ty:PayerMA Service ProgramInforma on Contact Telephone.

10 (800)537-8862 ELIGIBILITY Detail1-Medical Care4-Diagnos c X-Ray30-Health Benefi t Plan Coverage33-Chiroprac c35-Dental Care47-Hospital48-Hospital - Inpa ent50-Hospital - Outpa ent86-Emergency Services88-Pharmacy98-Professional (Physician) Visit - Offi ceA6-PsychotherapyAL-Vision (Optometry)MH-Mental HealthUC-Urgent CareMC-MedicaidCategory: JProgram Status: 37 Service Program: HCB50-ADULT1/19/19 ELIGIBILITY DETAIL OF ADULT BENEFIT PACKAGEEVS EXAMPLE #3 continuedCHECKING ELIGIBILITY & PARTICIPANT IDENTIFICATION CARDSS tatus:Managed CareService Type:30-Health Benefi t Plan CoverageInsurance Type:HM-Health Maintenance Organiza on (HMO)Plan01/19/2019 Benefi t Related En ty:Managed Care Organiza onCH2D-KEYSTONE FIRST COMMUNITY HEALTHCHOICESI nforma on ContactTelephone: (800)521-6007 Message TextPrimary Care Provider informa on is not on fi le for date of service DetailHEALTH PLAN CONTACT INFORMATIONM anaged Care Organiza onCH2D-KEYSTONE FIRST COMMUNITY HEALTHCHOICESI nforma on ContactTelephone: (800)521-6007 Status:Other or Addi onal PayorService Type:30-Health Benefi t Plan CoverageInsurance Type:MB-Medicare Part BEligibility01/19/2019 Benefi t Related En ty:PayerMEDICARE PART BPayer Iden fi er: 100 Message TextRecipient is dual eligible.