CorporateBusiness Services

Checking Beneficiary Eligibility

To ensure the accuracy and appropriate billing of Medicare covered home health and hospice services, the first vital step is to check a beneficiary's eligibility. Providers should also periodically review the beneficiary's eligibility information, as long as the patient is receiving services from your agency.

A Medicare beneficiary's eligibility should be checked, at a minimum:

  • Upon admission to your agency;
  • Prior to submission of the home health request for anticipated payment (RAP);
  • Prior to submission of the hospice notice of election (NOE); and
  • Prior to submission of each claim.

To check Medicare eligibility, you must have the following beneficiary information:

  • First and last name
  • Medicare number (i.e. Health Insurance Claim (HIC) number)
  • Date of birth (month, day, and 4-digit year)
  • Gender

Systems for Checking Medicare Eligibility

The following provides information about the systems available to CGS home health and hospice providers to check a beneficiary's eligibility.

myCGS – A CGS web portal that provides eligibility information based on the HIPAA 270/271 transaction.

  • Eligibility information is available 24 hours a day, 7 days a week (except when upgrades or maintenance are being done).
  • Requires a signed Electronic Data Interchange (EDI) Enrollment Agreement with CGS.
  • One agency representative registers as the Provider Administrator, and they may grant access to additional users.
    • myCGS Webpage
    • myCGS User Manual
    • CGS EDI Help Desk,
      • Home health and Hospice – 1-877-299-4500, choose Option 2

CGS IVR (Interactive Voice Response) – A CGS telephone-based system that provides eligibility information based on the Common Working File (CWF).

  • Eligibility information is available 24 hours a day, 7 days a week (except when upgrades or maintenance are being done).

HETS (HIPAA Eligibility Transaction System) – A Centers for Medicare & Medicaid Services (CMS) system, based on the HIPAA 270/271 transaction.

ELGA and ELGH – CMS eligibility systems that provide eligibility information based on the Common Working File (CWF).

NOTE:The Medicare Learning Network (MLN) Matters® article SE1249External PDF was revised on February 10, 2014, indicating that provider access to ELGA/ELGH, which was originally schedule to be terminated April 7, 2014, has been delayed. CMS will provide at least 90 days advanced notice of the new termination date. CMS is in the process of updating HETS to return Hospice period information in the same format as ELGA/ELGH. Providers should prepare for this by establishing one of the alternative systems listed above for checking eligibility.

Information Available from Medicare Eligibility Systems

All systems will display basic information, including:

  • Medicare entitlement and termination dates
  • Home health episode information
  • Hospice benefit periods
  • Medicare Advantage plan information
  • Medicare secondary payer information
  • Preventive benefit information

Revised: 11.15.16


Two Vantage Way, Nashville, TN 37228 ©2017 CGS Administrators, LLC. All Rights Reserved