Provider Manual

VERIFYING MEMBER ELIGIBILITY

In order to ensure reimbursement for services provided to a member of the HealthChoices Program, providers must verify the member’s date of eligibility and participation via one of the following methods:

1. Carelon Online Provider Services*
   • Go to pa.carelon.com
   • Click on “For Providers”
   • Next to“Provider Online Services” click “Login”
   • Enter the submitter identification number and password to login
   • Select “Eligibility Inquiry” to verify the member’s status
   • Enter the member’s 9-digit Medical Assistance identification number
   • Enter the member’s date of birth in ‘MM/DD/YYYY’ format

   *In order to be able to access the system, providers must first obtain a User ID and Password by clicking on Register, which is next to the Login button.

2. DHS’s PROMISe Website
   • Go to http://www.dhs.pa.gov/provider/promise/enrollmentinformation/S_001994 (new)
   • Log on to PROMISe or register
   • Click on “Eligibility” to enter the Eligibility Verification System (EVS)
3. DHS’s Eligibility Verification System (EVS)
   • Dial 1-800-766-5387
   • Enter the thirteen (13) digit Medical Assistance provider number
   • Select option #1 to enter the member’s 10-digit Medical Assistance identification number
   • Select option #2 to enter the member’s social security number
   • Enter the member’s date of birth in ‘MMDDCCYY’ format
   • Enter the date of service in ‘MMDDCCYY’ format

   Eligibility may be verified up to 365 days prior to the date of the call.

Keep in mind that member eligibility is highly variable. There are a multitude of eligibility changes that can impact service authorization and claims payment. For example, when a member moves to a new county, there may be a break or termination in HealthChoices eligibility. The member may return to fee-for-service. Members must register with the respective County Assistance Office (CAO) when there are changes in eligibility. These changes often result in gaps in eligibility.

Authorization is not a guarantee of payment. Payment is based on member eligibility at the time the service was rendered. IT IS THE PROVIDER’S RESPONSIBILITY TO VERIFY THE MEMBER’S ELIGIBILITY FOR EACH DATE OF SERVICE.