Corporate

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.

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

  • Access is available through a provider's existing Fiscal Intermediary Standard System (FISS) connection.

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: 11.17.17

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