Interactive Voice Response User Guide

Eligibility <1>

  • The date of service must equal today’s date, a date within the past four years, or a future date of no more than four months. Historical deductible information (Part B, physical, occupational)
  • Is unavailable for date of services beyond two years from today’s date. This option is not available for terminated providers.
  • The IVR will allow you to obtain LTR days remaining in all eligibility hospitals even if the date of service inquiry does not fall within an inpatient benefit period. \The IVR will indicate the lifetime psychiatric days remaining even if the date of service inquiry does not fall within an inpatient benefit period. Lifetime psychiatric days are only available to psychiatric provider types with a PTAN within xx4000–xx4499.

When the Eligibility option is selected, the IVR will request and collect the following elements:

  • NPI
  • PTAN
  • Last five (5) digits of the TIN
  • MBI
    • Refer to the Phonetic Alphabet for assistance with speaking alpha characters
  • Beneficiary first and last name (last name and first initial if using touch-tone)
  • Beneficiary date of birth
  • Date of service

Once the authentication elements have been verified, the IVR will supply the following, if applicable:

  • Railroad Medicare
    • If the beneficiary has coverage via Railroad Medicare, information will be provided on who to contact for additional information.
  • MBI MBI termination date, if applicable. If the MBI has been terminated, you must contact the beneficiary or use the MBI Lookup Tool located in NGSConnex to obtain the new MBI. If the date of service entered is after the termination date, eligibility information will not be provided.
  •  
  • Part A and Part B effective/termination dates
    • If there is no Part A and B coverage, no additional eligibility information will be provided
  • Reason for Medicare entitlement
  • Medicare inactive dates
    • Medicare is not responsible for coverage for the dates provided due to inactive status. Check with the beneficiary for the responsible party for coverage.
  • QMB program effective/termination dates
    • Beneficiaries that are in the QMB program are not responsible for deductibles or co-payments
  • Date of Death

The following sub-menus must be selected in order to hear the applicable components of eligibility. You may speak or enter the touchtone. After one sub-menu plays, you are able to select other sub-menu.

Full Eligibility (touchtone 1)

  • All eligibility components (listed below) will be advised

Basic Eligibility (touchtone 2)

  • Current year Part B deductible applied amount
  • Previous year Part B deductible applied amount
  • Physical therapy used amount
  • Occupational therapy amount

Hospital and SNF Billing (touchtone 3)

  • Last bill date
  • Inpatient hospital benefit days
  • Inpatient skilled nursing benefit days
  • Psychiatric benefit days available (only supplied to psychiatric providers)
  • LTR days

Other Insurance (Touchtone 4)

  • MSP type, insurer name, diagnosis code(s), and effective/termination dates
  • If the primary payer is limiting coverage to specific diagnosis codes, the diagnosis codes will be provided.
  • If the beneficiary has an MSP, you must bill the MSP first, then Medicare.
  • If the beneficiary has an MSP and a MA plan, you need to speak with the MA plan to determine correct billing (MSP first then MA plan or MA plan first).
  • MA plan number, name, option code, administering insurance company, and effective/termination dates.
  • The option code will provide more details in regards to who is responsible for the services rendered
  • The administering insurance company, if available, is the company administering the MA Plan.
  • If the beneficiary has an MA plan, you must contact the plan to determine billing and coverage

ESRD (touchtone 5)

  • End-stage renal disease coverage dates, dialysis dates and transplant date

Home Health and Hospice (touchtone 6)

  • Home health name, NPI, address, and effective/termination dates
  • Hospice name, NPI, address and effective/termination dates

Special Services (touchtone 7)

  • DSMT and MNT eligibility information including the initial date and minutes remaining for initial or follow up training (note: eligibility information for DSMT and MNT is based on today’s date)
  • COVID-19 vaccine (will provide the date the procedure code(s) were billed and the NPI of the billing provider, if applicable)
  • Last pneumococcal vaccine HCPCS code, vaccine date or date eligible for vaccine
  • Smoking cessation counseling date and number of sessions remaining
  • Pulmonary rehabilitation number of sessions remaining
  • Cardiac rehabilitation number of sessions used
  • Intensive cardiac rehabilitation number of sessions used
  • Acupuncture services date and number of sessions remaining

After Eligibility playback, the caller will be able to:

  • access additional sub-menus,
  • You may say “additional eligibility information” or the sub-menu you would like to hear
  • say “repeat that” in order to hear the information again
  • change date of service,
  • change the beneficiary’s Medicare number,
  • If you entered a MBI, you will be able to change to another MBI. If you entered a HICN you will be able to change to another HICN. If you entered a MBI and need to change to HICN, you will need to return to Main Menu.
  • return to the main menu,
  • barge to the next topic within eligibility by pressing the 9 on the keypad and
  • say “goodbye” to end call.