Eligibility <1>

Table of Contents

• Eligibility<1>
  • Full Eligibility (Touchtone 1)
  • Basic Eligibility (Touchtone 2)
  • Other Insurance (Touchtone 3)
  • ESRD (Touchtone 4)
  • Home Health and Hospice (Touchtone 5)
  • Special Services (Touchtone 6)
  • Providers with Specialty D1 – Medicare Diabetes Prevention Program

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Eligibility <1>

• Provide the current date or say “today” if the date of service is unknown or in the future. Eligibility is not available if date of service is greater than one year from the date you are calling the IVR.
• This option is not available for terminated providers.

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

• NPI
• PTAN
• Last five (5) digits of the TIN
• Beneficiary Medicare number
• 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
  • 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.

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 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 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.
• Qualified Medicare Beneficiary (QMB) program effective/termination dates
  • Beneficiaries that are in the QMB program are not responsible for deductibles or co-payments
• Date of Death

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Full Eligibility (Touchtone 1)

• All eligibility components (listed below) will be advised

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Basic Eligibility (Touchtone 2)

• Current/prior year Part B deductible status (met/not met)
• Current/prior year Part B deductible partial amount used
• Current/prior year physical therapy limit amount used
• Current/prior year occupational therapy limit amount used

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Other Insurance (Touchtone 3)

• 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.
• 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).

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ESRD (Touchtone 4)

• ESRD coverage dates, dialysis dates and transplant date

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Home Health and Hospice (Touchtone 5)

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

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Special Services (Touchtone 6)

• 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)
• Pneumonia vaccine (will provide the date of the vaccine if it exists or the date the beneficiary is eligible for the 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
• Historical MDPP Services
  • If services have been provided under the MDPP, the following information will be provided:
    • The procedure code of the service
    • The date of service
    • The rendering physician’s NPI
• Acupuncture services date and number of sessions remaining

Note: Deductible and co-insurance are not applicable for Medicare Diabetes Prevention Program services.

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Providers with Specialty D1 – Medicare Diabetes Prevention Program

Once the authentication elements have been verified, the IVR will supply the following, if applicable, for providers that only have a listed specialty of D1:

• Railroad Medicare
  • If the beneficiary has coverage via Railroad Medicare, information will be provided on who to contact for additional information.
• 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 B effective/termination dates
  • If the is no Part B coverage, no additional eligibility information will be provided
• 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.
• 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.
• 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).
• ESRD begin and end dates
• Date of death
• Historical MDPP services
  • If services have been provided under the MDPP, the following information will be provided:
  • The procedure code of the service
  • The date of service
  • The rendering physician’s NPI

Note: Deductible and co-insurance are not applicable for MDPP services.

After Eligibility playback, the caller will be able to:

Voice	Touch‐Tone Entry
Repeat	#
Change Date	No touch-tone availabe for this
Help	*

•  
• Access additional submenus,
  • You may say “additional eligibility information” or the submenu 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
• Return to the main menu
• Barge to the next topic within Eligibility by pressing the 9 on the keypad.
• Say “goodbye” to end call.