CMS monitors all Medicare Beneficiary eligibility transactions. When CMS identifies abnormal transactions ( e.g. high inquiry volume by NPI, high error rate, high rate of transactions for a single beneficiary, requesting psychiatric data by a non Psychiatric provider (NPI) Passport as your Clearinghouse, for these transactions, maybe asked to address improper use of the data. CMS outlines the authorized purposes for requesting Medicare Beneficiary eligibility data at: http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/downloads/HETS270271CompanionGuide5010.pdf.
Section 1.4.1 Authorized Purposes for Requesting Medicare Beneficiary Eligibility Information includes the following authorized purposes:
- Verify eligibility, after screening the patient to determine Medicare eligibility, for Part A and/or B coverage
- Determine Medicare Beneficiary payment responsibility with regard to deductible/copay
- Determine eligibility for other services such as preventive
- Determine if Medicare is the primary or secondary payer
- Determine if the Medicare Beneficiary is in the original Medicare plan, MA plan or Part D plan
- Determine proper billing
Section 1.4.2 Unauthorized Purposes for Requesting Medicare Beneficiary Eligibility Information includes the following authorized purposes:
- To determine eligibility for Medicare without first screening the patient to determine if they are Medicare eligible.
- To acquire the Medicare Beneficiary’s Health Insurance Claim Number (HICN).
Section 1.4.3 Note to Medicare Providers/ Suppliers..
The Medicare Beneficiary should be the first source of health insurance eligibility information. When scheduling a medical appointment for a Medicare Beneficiary, remind them to bring, on the day of their appointment, all health insurance cards showing their health insurance coverage. This will not only help you determine who to bill for services rendered, but also give you the proper spelling of the Medicare Beneficiary’s first and last name and identify their HICN as reflected on the Medicare Health Insurance card. If the Medicare Beneficiary has Medicare coverage but does not have a Medicare Health Insurance card, encourage them to contact the Social Security Administration at 1-800-772-1213 to obtain a replacement Medicare Health Insurance card. Those beneficiaries receiving benefits from the Railroad Retirement Board (RRB) can call 1-800-833-4455 to request a replacement Medicare Health Insurance card from RRB
Additional Information
- CMS is data is updated every 24 hours
- Benefit information is updated upon claim payment
