HH&H FAQs – Beneficiary Eligibility Information
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- 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: 9/25/2019
- 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: 9/25/2019
- 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: 9/25/2019
- 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 Contacts
directory 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: 9/25/2019
- 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: 9/25/2019
- 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: 9/25/2019
- 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 Eligibility
of 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 Fields
quick 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: 9/25/2019
- Where can I find more information about patient eligibility?
Chapter Two – Checking Beneficiary Eligibility
of 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 Guide
for 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: 9/25/2019
- 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: 9/25/2019
- 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: 9/25/2019
- 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: 9/25/2019