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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
  • 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.

Fiscal Intermediary Standard System Direct Data Entry (FISS DDE) – The Beneficiary/CWF (Option 10) is available from the FISS DDE Inquiry Menu.  Once Option 10 is selected, you must have the following five pieces of information about the beneficiary.

  • Medicare ID number (known as the Medicare Beneficiary Identifier (MBI))
  • Last Name
  • First Name
  • Gender (M/F)
  • Date of Birth (MMDDCCYY format)

Refer to the FISS DDE Guide Chapter 3: Inquiry MenuPDF for additional information about the Beneficiary/CWF (Option 10).

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

NOTE: In December 2012, CMS announced plans to discontinue the CWF Beneficiary eligibility transactions (MLN Matters Special Edition article SE1249External PDF).  In that same article, CMS announced that the HETS would be the single source for this data.  If you currently use CWF queries (HIQA, HIQH, ELGA, and ELGH) to obtain Medicare eligibility information, you should begin using HETSExternal PDF

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: 01.28.20

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