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Part A FAQs –Medicare Advantage

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  1. Where can I find a list of Medicare Advantage Plans?
  1. We have a patient who recently terminated her HMO coverage and does not know her Medicare Number. I've called the contact center and tried to verify eligibility, but am told they are unable to verify Medicare eligibility with only an HMO member number. What can I do?

    • The Provider Contact Center (PCC) must adhere to CMS guidelines and verify the patient's Medicare number, full name and date of birth prior to releasing information.

      Please note: The PCC will only verify eligibility if one of the following is unavailable: the Interactive Voice Response (IVR) Unit, the Direct Data Entry (DDE) eligibility function, or the myCGS web portal.

      There is no reference to the MBI Look-up Tool on myCGS, which requires the Patient's First and Last Name, SSN, and Date of Birth. The MBI Look-Up Tool is something that the PCC will refer providers to if they state during the call that they are looking for the patient's Medicare number.

      Reviewed 3/18/2024
  1. Upon admission, patients will frequently present a traditional Medicare card and a Medicare Advantage card. What is the appropriate process for verifying their eligibility?

    • We encourage providers to ask their Medicare patients whether they have changed insurance each time they visit. If a member presents both a Medicare Advantage ID card and an original Medicare ID card, the provider should confirm Medicare Advantage eligibility and then disregard the original Medicare ID card.

      The providers can review both traditional Medicare Eligibility, as well as Medicare Advantage information through eligibility options of HETS, MyCGS, or by calling the IVR.

      Reviewed 3/18/2024
  1. Where can I find out more about Medicare Advantage plans?
  1. What do you do when a claims falls within or overlap with a Medicare Advantage (MA) Managed care plan enrollment period?
      • Obtain the managed care plan information from the Direct Data Entry (DDE) system, the Interactive Voice Response (IVR), or the myCGS web portal. Submit a claim to the managed care plan for payment.
      • For certain inpatient services, an informational-only claim must be submitted to Medicare for the purpose of tracking benefit utilization and, in some cases, for the provider to receive special payments. Informational-only claims are submitted as follows:

          Acute IRF LTCH CAH SNF/SB
        Non-teaching facility Covered claim with condition code 04 for Disproportionate Share Hospital (DSH) payment Covered claim with condition code 04 and the Case-Mix Group (CMG) code and assessment date from the IRF Patient Assessment Instrument (PAI) for Low-Income Patient (LIP) payment Covered claim with condition code 04 for DSH payment Covered claim with condition code 04 for Electronic Health Record (EHR) incentive payment Submit claim to the managed care plan for payment; submit the same claim to Medicare to track benefit utilization
        Teaching facility Covered claim with condition codes 04 and 69 for DSH and Direct Graduate Medical Education (DGME) payments Non-covered claim with condition codes 04 and 69 for LIP and DGME payments Non-covered claim with condition codes 04 and 69 for DSH and DGME payments Not applicable Not applicable


      • Note: Managed care informational-only claims are not required for outpatient hospital or Inpatient Psychiatric Facility (IPF) services. If requesting a denial based on coverage by a managed care plan, submit the claim as covered without condition code 04 or 69.
      • If the beneficiary is enrolled in a managed care plan for only a portion of an inpatient stay, submit the claim as follows:

        IPPS IPF IRF LTCH CAH Non-IPPS SNF/SB
        • If Medicare is primary upon admission, bill the entire claim to Medicare.
        • If the managed care plan is primary upon admission, bill the entire claim to the managed care plan.
        • Bill the managed care plan for days the patient is enrolled in the managed care plan.
        • Bill Medicare for the days the patient is not enrolled in the managed care plan.

        Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1External PDF, section 90

      • If the beneficiary is enrolled in a managed care plan and elects the hospice benefit, all hospice and non-hospice related services beginning on the date of the hospice election are billed to Medicare as follows:
        • Hospice services covered under the Medicare hospice benefit are billed by the hospice provider to the Home Health and Hospice (HH&H) Medicare Administrative Contractor (MAC).
        • Services provided by the enrollee's attending physician (if the physician is not employed by or under contract to the enrollee's hospice) are billed by the physician to Part B of the A/B MAC.
        • Services not related to the treatment of the terminal condition are billed by the provider to Part A of the A/B MAC with condition code 07.
        • Services furnished after the revocation or expiration of the enrollee's hospice election are billed accordingly until the full monthly capitation payments begin again. Monthly capitation payments begin on the first day of the month after the beneficiary revokes the hospice election.

        Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11External PDF, section 30.4

      Reviewed 3/18/2024

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