- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Checking Eligibility and Knowing your Point of Contact
Table of Contents
- Checking Eligibility and Knowing your Point of Contact
- How to Verify Patient Eligibility
- Related Content
- Listed below are the different patient eligibility and entitlement types and the points of contact to request additional details and status updates
Checking Eligibility and Knowing your Point of Contact
There are many different types of coverage and patient statuses which can affect a beneficiary’s Medicare coverage and the processing of claims.
When a Medicare patient comes to your office, we recommend that you make a copy of their Medicare card. Failure to indicate the beneficiary’s name and identification number exactly as it appears on the Medicare card may result in a claim delay/denial. You may also want to establish a process by which insurance information is verified at the beginning of each year and at certain intervals to ensure the information has not changed. If a change has occurred, your patient’s records will need to be updated to reflect the most current information.
Incorrect eligibility information can wreak havoc on your claim submissions and/or payments. Listed below are some of the issues you may experience if the eligibility information is not up-to-date:
- Delay in payments
- Increase in:
- Claim denials
- Write offs
- Denial rates
- Overpayments and/or recoupments
How to Verify Patient Eligibility
The CMS requires contractors to offer self-service and electronic communication technologies as efficient, cost-effective means of disseminating Medicare provider information, education and assistance.
Eligibility can only be obtained via one of our following self-service tools:
- Log in to the NGSConnex portal to access national eligibility information to obtain Medicare beneficiary entitlement, MCO enrollment, MSP information, preventative services, therapy caps and much more.
- Call the Interactive Voice Response System to verify if Medicare is primary or secondary, coverage dates, deductible information, therapy limits and more.
- CMS offers real-time Internet-based eligibility transactions as an alternative to the IVR. These 270/271 transactions are processed through the CMS data center. Providers and clearinghouses must be authenticated by CMS before conducting these transactions. Telecommunications software is also required in order to access the CMS network. For more information, visit the HIPAA Eligibility Transaction System (HETS).
Related Content
Listed below are the different patient eligibility and entitlement types and the points of contact to request additional details and status updates
End-Stage Renal Disease
When a patient elects to receive dialysis, the ESRD facility is responsible for services related to their dialysis. Providers may confirm if a service is related to the patient’s stay by speaking with the ESRD facility. For services not related, providers may append modifier AY.
Medicare providers are responsible for the collection and maintenance of patient information. They must determine if a patient is eligible for Medicare and if Medicare is the primary or secondary payer.
- Providers must contact ESRD facility to confirm if a service is related to a beneficiary’s stay
- If national file is incorrect, providers must contact ESRD facility and/or patient to request updates to patient’s ESRD record
- If file is correct, providers must work with ESRD facility to seek payment for their services
- National Government Services is unable to make any changes to ESRD facility claims on national file or pay for ESRD-eligible services
Related Content
Home Health Agency
When a beneficiary elects home health through a home health agency, the Medicare services received are subject to home health consolidated billing and include nursing and therapy services, routine and non-routine medical supplies. Home health and medical social services are not paid separately by Medicare but are paid to the home health agency.
- All HHA information on national file is maintained by HHA.
- If file is incorrect, providers must contact HHA and/or patient to request updates to HHA record.
- If file is correct, providers must work with HHA to seek payment for their services.
- NGS is unable to make any changes to HHA records on national file or pay for HHA eligible services.
Related Content
- CMS Consolidated Billing Coding and Billing Information
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7
Hospice
When a beneficiary elects a hospice, they waive all rights to Medicare payments for services related to the treatment of the terminal condition(s) or related condition equivalent to hospice care. Bill the attending physician services, who is not employed by hospice, with modifier GV. Bill services unrelated to terminal illness with modifier GW.
- All hospice information on national file must be updated by hospice.
- If file is incorrect, providers must contact hospice and/or patient to request updates to hospice record.
- If file is correct, providers must work with hospice to seek payment for their services.
- NGS is unable to make any changes to hospice records on national file or pay for hospice eligible services.
Related Content
Hospital
When a beneficiary is considered inpatient in a hospital, Medicare Part B is responsible for the professional services. Providers submitting their professional services must bill using the appropriate place of service matching the patient's status. For pathology services, providers may submit the technical component to Part B only when the referring provider has received payment outside of the hospital for the same date of service.
- Hospital claims on national file are updated by hospital.
- Providers must contact hospital and/or patient to request an update to hospital claim or seek payment for services rendered.
- NGS is unable to make changes to hospital claims.
Incarceration/Unlawfully Present
When a patient is a prisoner in custody and/or incarcerated, services are not covered by Medicare. Applicable federal, state or local authority may cover such claims. This includes situations such as home detention, supervised release, medical furlough, required residence in a mental health facility or a halfway house.
- Social Security is responsible for maintaining a patient’s incarceration record.
- Providers must contact appropriate authority responsible for patient’s custody to request an update to patient’s national file or seek payment for services rendered from local authority.
Related Content
Medicare Advantage Plan, Health Maintenance Organization, Preferred Provider
When a beneficiary elects an alternative to the traditional fee-for-service Medicare Program, providers bill the alternative Medicare Advantage, HMO or PPO plans.
- If file is incorrect, providers must contact the plan and/or patient to request updates to plan record.
- If file is correct, providers must work with the plan to seek payment for their services.
- NGS is unable to make any changes to plan records on national file or pay for plan eligible services under most circumstances; exceptions for hospice, clinical trials and inpatient status may be applicable.
Related Content
Medicare Secondary Payer
Patients may have insurance paying before Medicare and Medicare becomes secondary to a primary insurance. A/B and DME MACs may update and create MSP records based on MSP information found on Medicare claims.
Providers, physicians and other suppliers may contact the BCRC to:
- verify Medicare’s primary/secondary status,
- report changes to a beneficiary’s health coverage,
- report a beneficiary’s accident/injury or
- ask questions regarding Medicare development letters and questionnaires.
BCRC representatives are available Monday through Friday, 8:00 a.m.‒8:00 p.m. ET, at 855-798-2627 (TTY/TDD: 855-797-2627 for the hearing and speech impaired).
Note: Insurer information will not be released. The provider must request information on payers primary to Medicare from the beneficiary prior to billing. Since the rights and information of beneficiaries must be protected, the BCRC cannot disclose this information.
Related Content
Skilled Nursing Facility
When a beneficiary is considered inpatient in a SNF, services such as non-professional services, physical therapy and ambulance transportation between two SNFs are subject to skilled nursing consolidated billing. If the service allows, provider may bill for the professional component to Medicare Part B.
- SNF claims on national file are updated by the SNF.
- Providers must contact SNF and/or patient to request an update to SNF claim or seek payment for services rendered.
- Provider Contact Center is unable to make changes to SNF claims or pay for SNF eligible services.
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6
- CMS Part B SNF Consolidated Billing File Explanation
Social Security Administration
The SSA maintains a beneficiary’s Medicare eligibility regarding the spelling of his/her name, date of birth, date of death, requests for new Medicare cards, effective/termination dates and/or related updates to Medicare information.
- Providers must request patient contact SSA to update these files.
SSA Phone Number: 1-800-772-1213 (TTY 1-800-325-0778)
Supplemental Insurance Coverage
When a beneficiary has an insurance secondary to Medicare, those insurance agencies work with Medicare contractors to define the types of finalized claims (adjusted, initial, unprocessable) sent to them for processing. Each insurance company must provide accurate, timely files. When applicable, a provider’s Medicare RA. will reflect the name of the supplemental insurance Medicare sent the claim-specific RA.
Supplemental insurance coverage files must be updated by supplemental insurance or BCRC.
- If file is incorrect, providers must contact supplemental insurance, patient, and/or BCRC to request updates.
- If an error occurred in the crossing over of a Medicare claim to supplemental insurance occurs, provider must contact supplemental insurance to submit Medicare RA.
- NGS is unable to make any changes to supplemental records on national file or attempt a second crossover attempt to them.
BCRC representatives are available Monday through Friday, 8:00 a.m.‒8:00 p.m. ET, at 855-798-2627 (TTY/TDD: 855-797-2627 for the hearing and speech impaired).
Revised 10/23/2023