RCPA - Rehabilitation and Community Providers Association


Changes to Medical Assistance EVS
January 4, 2012

December 2012 brought issuance of Medical Assistance (MA) Provider Quick Tip #148 on Council for Affordable Quality Healthcare (CAQH), Committee on Operating Rules for Information Exchange (CORE) changes to streamline eligibility, benefits, and claims data. Changes to 270/271 eligibility transactions are effective for the Eligibility Verification System (EVS) on January 1. The Interactive Voice Response System (IVRS), Inter/Intranet web pages, and Provider Electronic Solutions (PES) software are affected. The PES changes will occur on the next PES release date.

The following changes were effective for EVS on January 1:

  • Co-payment/deductible/co-insurance information is displayed;
  • Multiple error codes are returned on the 271, one for each error condition encountered;
  • A new error code is added – 73, Invalid Missing Subscriber/Insured Name;
  • Service Type Request search availability, but IVRS will not accept service type in the request;
  • Eligibility for future date of service until the end of the current month;
  • Improved searching by name; and
  • Two new connectivity methods (HTTS/SOAP and HTTS/MIME) for submitting batch and interactive transactions.

The 270/271 PROMISe Companion Guide contains more information on the CAQH/CORE changes. The MA Copayment Desk Reference that indicates copayment amounts and exclusions is available.

The Centers for Medicare and Medicaid Services Office of E-Health Standards and Services (OESS) announced that it will not begin enforcement of Affordable Care Act operating rules for transactions for eligibility for a health plan and health care claim status until March 31, although the compliance date remains January 1. HIPAA covered entities may still be working toward compliance and those that are prepared can use the new operating rules. Complaints may be filed during the enforcement delay and entities would be required to submit evidence of compliance or a good faith effort to achieve compliance to the OESS. The operating rules for eligibility for a health plan and health care claim status transactions are available on the CAQH web site.  More information on the operating rules for eligibility for a health plan and health care claim status is available at http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/OperatingRulesforEligibilityandClaimsStatus.html

PCPA members may contact Betty Simmonds with questions.

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