License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Part B Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a fourth party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a fourth party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a fourth-party beneficiary to this Agreement.
5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

HH&H FAQs – Beneficiary Eligibility Information

<< Return to the full list of HH&H FAQ topics

---

Click on an item to expand or Show All / Close All

1. When trying to access beneficiary eligibility information on ELGH or ELGA, I get a message that says TNIF. What does this mean?

   • A message containing the phrase TNIF (True Not In File) typically appears when the beneficiary's eligibility file is being updated, which may prevent you from being able to access their information. Try accessing the beneficiary's information at a later time. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 and MM8248 for more information.

     Reviewed:

     12/30/2019

2. What should we do if there is an open Medicare Secondary Payer (MSP) record posted to the beneficiary's eligibility file that has a really old effective date?

   • MSP records posted to the Common Working File are the responsibility of the Benefits Coordination and Recovery Center (BCRC) (formerly known as the Coordination of Benefits Contractor (COBC)), and they are the only entity able to update these records. To reach the BCRC, please call 1-855-798-2627 (8:00 a.m. to 8:00 p.m. ET). See Medicare Learning Network (MLN) Matters® SE1416" Updating Beneficiary Information with the Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor) for assistance when working with the BCRC.

     Reviewed:

     12/30/2019

3. Where can we verify the beneficiary's demographic information, such as their date of birth or name we should be submitting to Medicare?

   • Home health and hospice providers should first consult with the beneficiary for their name and date of birth. To obtain the Medicare health insurance claim (HIC) number or Medicare Beneficiary Identifier (MBI), and eligibility information providers should also review the beneficiary's red, white and blue Medicare card. The beneficiary's information submitted on your claim should match exactly as it appears on the beneficiary's eligibility file. For the different options available for checking Medicare eligibility, refer to the "Checking Beneficiary Eligibility" web page.

     Reviewed:

     12/30/2019

4. If we determine that the Medicare Advantage (MA) enrollment period posted to the beneficiary's eligibility file is incorrect, how can we resolve this?

   • If the MA plan enrollment period is posted to the beneficiary's eligibility file in error, the MA plan will need to correct this information. Providers should contact the MA plan directly to update the beneficiary's record. The MA Claims Processing Contactsdirectory contains a list of all active Medicare contracts, and contact information for the MA plan. If using the myCGS web portal, this information is found on the "Plan Coverage" tab located within the "Eligibility" tab. Please see the myCGS User Manual (Chapter 4: Eligibility Tab) for additional information regarding the "Plan Coverage" tab.

     Please be aware that until the beneficiary's eligibility file is updated, any claims submitted to CGS will be impacted by the incorrect MA plan information; therefore, providers should not submit Medicare claims until the MA plan information is corrected.

     Reviewed:

     12/30/2019

5. Will all Medicare Advantage (MA) beneficiaries have a Medicare number to check this eligibility information in ELGA/ELGH?

   • Yes, all Medicare beneficiaries receive a Medicare ID number, regardless of whether they receive services under the traditional Medicare fee-for-service (FFS) plan (Part A or B benefits), or an MA plan (Part C benefits). Using the beneficiary's Medicare ID Number, name, date of birth and sex code, all providers can access the beneficiary's eligibility information to determine whether the beneficiary has elected an MA plan.

     The MA plan information is available on Page 1 in ELGA, and on Page 5 in ELGH. Please see Chapter Two – Checking Beneficiary Eligibility of the Fiscal Intermediary Standard System (FISS) Guide for additional information on understanding the information posted to these pages. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 and MM8248 for more information.

     In the myCGS web portal, this information is found on the "Plan Coverage" tab located within the "Eligibility" tab. Please see the Chapter 4: Eligibiity Tab of the myCGS User Manual for additional information regarding the "Plan Coverage" tab.

     Reviewed:

     12/30/2019

6. If eligibility is checked in the Common Working File (CWF) prior to admission and comes back "clean" i.e., no Medicare Advantage (MA) plan, can a denied claim be appealed if a retroactive MA record suddenly appears in CWF? We print out every eligibility record so we have "proof" that it was checked and okay before the case was opened. Also, are there any timeframes to which the CWF record can be retroactively updated?

   • A claim determination regarding services that overlap a beneficiary's enrollment in a Medicare Advantage plan cannot be appealed. When no Medicare payment is made for reasons related to eligibility, the claim is rejected, (R status code) or sent back to the provider for correction, (T status code). If appropriate, a claim can be resubmitted for the dates of service outside of the MA plan's eligibility dates. There are no timeframes that exist for the Common Working File (CWF) to update the beneficiary's records. At a minimum, we encourage providers to check eligibility at the time of admission, once a month, and prior to submitting any billing transactions to Medicare. This ensures that you have the most current MA plan information prior to billing. In addition, you should also check all insurance cards (including Medicare Part D) the beneficiary holds to account for all insurance coverage that the beneficiary may have.

     Reviewed:

     12/30/2019

7. How can I find out what patient information is available in ELGA/ELGH, myCGS or the HIPAA Eligibility Transaction System (HETS) application?

   • To review what critical beneficiary eligibility information is available in the ELGA/ELGH screens, please review Chapter Two – Checking Beneficiary Eligibilityof the Fiscal Intermediary Standard System (FISS) Guide. This resource will walk you through each screen and provide a description of the fields found on them. The ELGA-ELGH Overview of Key Fieldsquick resource tool, which highlights the important fields on these screens, is also available. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 and MM8248 for more information.

     The myCGS User Manual consists of seven chapters, containing screenprints and field descriptions for the beneficiary eligibility information found in this application. The HETS 270/271 Companion Guide provides specific details about the eligibility information that is returned in the HETS 271 response.

     Reviewed:

     12/30/2019

8. Where can I find more information about patient eligibility?

   • Chapter Two – Checking Beneficiary Eligibilityof the Fiscal Intermediary Standard System (FISS) Guide contains details about the information found on the ELGH/ELGA screens, as well as the field descriptions, and the interpretation of the data found in the fields. Please note that provider access to ELGA/ELGH will be terminated in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 and MM8248 for more information.

     When using the myCGS web portal to check beneficiary eligibility information, see the myCGS User Manual for additional information. See the HETS 270/271 Companion Guidefor the HIPAA Eligibility Transaction System (HETS) when using this application to verify patient information.

     For additional information about checking eligibility, refer to the "Checking Beneficiary Eligibility" Web page on the CGS website.

     Reviewed:

     12/30/2019

9. I have a claim that needs correcting and the reason code says that the beneficiary's name doesn't match the eligibility record. Where can I find out what information doesn't match?

   • After reviewing the information found on the beneficiary's eligibility file, compare this to what is on FISS Pages 1 and 5 and note any inconsistencies. For example, is there an initial for the first name, which does not appear on your claim? Are there any spaces before or after the name? The patient's name submitted on your Medicare billing transactions should match exactly as it appears on the beneficiary's eligibility file. If the claim information is inconsistent, make any necessary corrections to the information found on both FISS Pages 1 and 5 and resend the claim for processing.

     See FAQ #3 above for information about options for verifying the beneficiary's eligibility information.

     Reviewed:

     12/30/2019

10. Where can I find out what Medicare number or the appropriate beneficiary name I need to use?

    • Eligibility information can be obtained from a variety of sources. The patient should be consulted to obtain the Medicare entitlement information (Part A and/or Part B), effective and termination dates, and the health insurance claim number or Medicare Beneficiary Identifier (MBI). All of this data is printed on the beneficiary's Medicare card. Eligibility information can also be found on ELGH/ELGA, the HIPAA Eligibility Transaction System (HETS), and myCGS. Use these applications when it is difficult to obtain information from the beneficiary and to validate the information received from the beneficiary is accurate.

      Please note that provider access to ELGA/ELGH will be terminated effective in the future. See Medicare Learning Network (MLN) Matters® article, SE1249 and MM8248 for more information. For more information about the systems available for checking eligibility, refer to the "Checking Beneficiary Eligibility" Web page on the CGS website.

      Reviewed:

      12/30/2019

11. Do I need to enter my National Provider Identifier (NPI) in ELGA and ELGH?

    • Yes. Your NPI is a required field when accessing beneficiary eligibility information through the Common Working File (CWF) inquiry systems ELGA and ELGH. In addition, Effective April 1, 2019, CWF will verify the NPI entered is valid. If you enter an invalid NPI, the message "Invalid NPI Number Submitted" will display. Refer to MM10983 for additional information.

      Reviewed:

      12/30/2019