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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, 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 websiteExternal 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.

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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.

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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.

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  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 websiteExternal Website.
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myCGS

myCGS User Manual

Eligibility

The myCGS eligibility function is based on CMS' HIPAA Eligibility Transaction System (HETS). When you choose the "Eligibility" tab, you will see a new set of sub-tabs with information related to your inquiry. Information is presented on the following:

  • Inquiry
  • Eligibility
  • Deductibles/Caps
  • Preventive
  • Plan Coverage
  • Medicare Secondary Payer (MSP)
  • Hospice/Home Health
  • Inpatient
  • Qualified Medicare Beneficiary (QMB)

 

NOTE: myCGS uses CMS' HETS 270/271 system, as required by CMS, for all eligibility inquiries. Although myCGS pulls data from HETS in real time, the data available in the HETS 270/271 system is updated only at certain times. CMS currently pulls the updated data Tuesday through Saturday during the hours of 6:00 p.m. - 8:00 p.m. This data is then uploaded into HETS during the hours of 9 p.m. to 6 a.m. As soon as updated data is available in the HETS 270/271 system, users will be able to view it in myCGS.

"Eligibility" Tab

To access beneficiary eligibility information, click on the "Eligibility" tab. Once selected, myCGS defaults to the "Inquiry" sub-tab.

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Inquiry

Use the "Inquiry" sub-tab to enter beneficiary information to submit an eligibility request. To ensure accurate information is provided to you, all fields entered, including optional fields, must be an exact match to the data maintained in CMS' HETS.

The following combination of fields are required:

  • Subscriber's Medicare ID, Last Name, and First Name, or
  • Subscriber's Medicare ID, Last Name, and Date of Birth

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To ensure accurate historical data is returned, be sure to enter a date range in the Optional Fields area. You may enter dates up to four (4) years prior to, and four (4) months in the future of, the current date. Date ranges may not exceed 12 months at a time.

Click "Submit Inquiry" to obtain eligibility information. Once retrieved, all the other sub-tabs will populate with data related to that beneficiary and, if applicable, the date range entered.

For your convenience, you have the option of printing each individual sub-tab or the entire eligibility record.

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Eligibility

The "Eligibility" sub-tab provides information regarding the beneficiary's Medicare coverage. If information does not populate, for example, either the "Part A Eligibility" or "Part B Eligibility" benefit information, it means the beneficiary is not eligible to receive Medicare benefits for the dates entered on the inquiry screen.

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The following tables provide information for the "Eligibility" sub-tab fields:

Part A Eligibility Benefit Information

Field Name Description

Effective Date

The start of eligibility for Medicare Part A benefits.

Termination Date

The termination of eligibility for Medicare Part A benefits. No date in this field means Medicare Part A eligibility has not terminated.

Part B Immunosuppressive Drug Eligibility

The Part B Immunosuppressive Drug (Part B-ID) benefitExternal website is for patient who will lose End-Stage Renal Disease (ESRD) Medicare coverage 36 months after a kidney transplant and who don't have, and don't expect to have, certain other types of health care coverage. Starting January 1, 2023, this benefit will help continue to pay for immunosuppressive drugs.

myCGS will allow you to view Part B ID information for patients who are eligible.

Field Name Description

Effective Date

A date that indicates the start of Part B ID benefits

Termination Date

A date that indicates the end of Part B ID benefits

Part B Eligibility Benefit Information

Field Name Description

Effective Date

The start of eligibility for Medicare Part B benefits

Termination Date

The termination of eligibility for Medicare Part B benefits. No date in this field means Medicare Part B eligibility has not terminated.

Inactive Periods

Field Name Description

Effective Date

A date that indicates the start of an inactive period due to unlawful, deported, or incarcerated reasons

Termination Date

A date that indicates the end of an inactive period due to unlawful, deported, or incarcerated reasons

Beneficiary Address

Field Name Description

Address

The address line 1 of the beneficiary

Address 2

The address line 2 of the beneficiary, if available

City

The city of the beneficiary

State

The state of the beneficiary

Zip

The ZIP code of the beneficiary

End Stage Renal Disease (ESRD) Information

Field Name Description

Effective Date

The date that indicates the start of eligibility for ESRD services

End Date

The date eligibility for ESRD services ended

Dialysis Start Date

The date the patient began dialysis

Dialysis End Date

The date dialysis ended for the patient

Transplant Effective Date

The date the patient received a transplant

NOTE: The ESRD section displays only active ESRD data and will not be available if no notification has been received by CMS indicating an ESRD period is active and in effect per the date(s) requested.

MBI End Date
When a beneficiary's Medicare Beneficiary Identifier (MBI) is compromised, a new MBI is assigned and the previous is deactivated. The deactivation date will appear here.

Prior Authorization
Currently, certain hospital outpatient department (OPD) services and Repetitive Scheduled Non-Emergent Ambulance Transports (RSNAT) require prior authorization. If you need help determining whether a specific CPT/HCPCS code you bill requires prior authorization, check here for links to the Prior Authorization Decision Tree. Simply answer a series of YES/NO questions and this tool will help.

Medicare Diabetes Prevention Program (MDPP)
Patients who receive dedicated evidence-based services aimed to help prevent an indication of pre-diabetes from progressing to an onset of Type 2 diabetes will have information populated in this section, including coverage dates, HCPCS code G9873, the billing provider's National Provider Identifier (NPI), as well as specific dates of service.

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Deductibles/Caps

The "Deductibles/Caps" sub-tab provides information regarding the beneficiary's Part B deductibles, co-insurance, occupational/physical/speech therapy caps, and other services.

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The following tables provide information for the "Deductible/Caps" sub-tab fields:

Part B Deductible

Field Name Description

Start/End Date

The beginning and end dates for the annual deductible

Deductible Amount

The Medicare Part B deductible amount associated with the calendar year

Part B Remaining Deductible

Field Name Description

Start/End Date

The beginning and end dates for the annual deductible

Remaining Deductible

The Medicare Part B deductible amount remaining for the calendar year

Co-insurance Details

Field Name Description

Start/End Date

The beginning and end dates for the annual co-insurance

Co-insurance Amount

The percentage of the patient's financial responsibility for Medicare Part B services

Blood Deductible

Field Name Description

Calendar Year

The calendar year associated with the remaining deductible amount

Number of Units Remaining

The blood deductible units remaining associated with the calendar year indicated

Occupational Therapy Cap

Field Name Description

Calendar Year

The calendar year associated with the capitation limit

Amount Used

The amount of allowed occupational therapy services applied

Physical and Speech Therapy Cap

Field Name Description

Calendar Year

The calendar year associated with the capitation limit

Remaining Amount

The amount of allowed physical and speech-language pathology applied

Pulmonary Rehabilitation Services

Field Name Description

Calendar Year

The calendar year associated with the pulmonary rehabilitation services

Professional Sessions Remaining

The number of pulmonary rehabilitation sessions remaining for the professional component

Technical Sessions Remaining

The number of pulmonary rehabilitation sessions remaining for the technical component

Cardiac Rehabilitation Services

Field Name Description

Calendar Year

The calendar year associated with the cardiac rehabilitation services

Professional Sessions Used

The number of cardiac rehabilitation sessions used for the professional component

Technical Sessions Used

The number of cardiac rehabilitation sessions used for the technical component

Intensive Cardiac Rehabilitation Services

Field Name Description

Calendar Year

The calendar year associated with the cardiac rehabilitation services

Professional Sessions Used

The number of intensive cardiac rehabilitation sessions used for the professional component

Technical Sessions Used

The number of intensive cardiac rehabilitation sessions used for the technical component

Part B Free Services

Field Name Description

STC Codes

The Health Care Service Type Codes (STC) identify classifications of services or benefits. For definitions of the two-digit codes, view the link for "List of STC Codes."

Value

The patient's portion of responsibility for a benefit, represented as a percentage

Start/End Date

The start and end dates of the benefit period

Mental Health Co-insurance

Field Name Description

STC Codes

The Health Care Service Type Codes (STC) identify classifications of services or benefits. For definitions of the two-digit codes, view the link for "List of STC Codes." This section is specific to mental health.

Value

The patient's portion of responsibility for a benefit, represented as a percentage

Start/End Date

The start and end dates of the benefit period, typically the first day of the calendar year indicated

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Preventive

The "Preventive" sub-tab provides information regarding preventive services the beneficiary has received.

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The following tables provide information for the "Preventive" sub-tab fields:

COVID-19 Immunization

myCGS will display the most recent information for the COVID-19 vaccines, boosters, and its administration.

Field Name Description

Immunization Date

The date the patient received the COVID vaccine/booster and/or administration of the vaccine.

HCPCS Code

Lists the specific vaccine/booster code the patient received and its corresponding administration code(s).

Rendering NPI

The National Provider Identifier (NPI) of the provider who rendered the vaccine/booster and its administration.

Pneumococcal Vaccine (PPV)

This section identifies the dates of service the beneficiary received PPV (by CPT code) and the rendering provider's NPI.

Field Name Description

Vaccination Date

The date the patient received the PPV vaccine

HCPCS Code

Lists the specific code of the vaccine the patient received

Rendering NPI

The National Provider Identifier (NPI) of the provider who rendered the vaccine

Cognitive Assessment and Care Plan Services

This section identifies if your patient received this service if signs of cognitive impairment were observed during a routine visit. Medicare covers a separate visit to assess your patient’s cognitive functionExternal website and develop a care plan more thoroughly.

Field Name Description

Date of Service

The date the patient received the service

HCPCS Code

Lists CPT code 99483, which is used to bill Cognitive Assessment & Care Plan Services

Rendering NPI

The National Provider Identifier (NPI) of the provider who rendered the service

Flu Vaccination

You will find the patient's flu vaccination history in this section.

Field Name Description

Vaccination Date

The date the patient received a flu shot

HCPCS Code

Lists the specific code of the vaccine the patient received

Rendering NPI

The National Provider Identifier (NPI) of the provider who rendered the vaccine

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Smoking Cessation Information

Any smoker covered by Medicare is eligible to receive tobacco cessation counseling from a qualified physician/practitioner who can work with them to help them stop using tobacco.

Field Name Description

Number of Sessions in Benefit Period

Number of smoking cessation counseling sessions available for a beneficiary during the benefit period

Initial Session Date

The beginning date for smoking cessation counseling

Benefit Period Sessions Remaining

Number of smoking cessation counseling sessions remaining for a beneficiary

Accupuncture

Effective for claims with dates of service (DOS) on and after January 21, 2020, Medicare will cover acupuncture for chronic Low Back Pain (cLBP)External PDF.

Field Name Description

Professional Sessions Eligibility date

The date the patient began receiving professional acupuncture services.

Professional Sessions Remaining

The number of professional sessions the patient has left in the benefit period (out of a total of 20 sessions.)

Technical Sessions Eligibility Date

The date the patient began receiving professional acupuncture services.

Technical Sessions Remaining

The number of technical sessions the patient has left in the benefit period (out of a total of 20 sessions.)

Deductible Remaining by Spell

This section identifies the Medicare-approved preventive services the beneficiary has received by CPT/HCPCS code and code description. Also, the dates the beneficiary is next eligible to receive services are listed as appropriate.

NOTE: Only HCPCS codes for which a beneficiary is eligible will be displayed and grouped together under their appropriate categories. If a service has been rendered, it is removed from the list until closer to the time the beneficiary is eligible to receive the service again.

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Field Name Description

HCPCS Code

The CPT or HCPCS code identifying the preventive service

HCPCS Label

A short descriptor of the CPT/HCPCS code identified in the first column

Next Professional Date

The date a beneficiary is next eligible for professional services associated with the indicated CPT/HCPCS code

Next Technical Date

The date a beneficiary is next eligible for technical services associated with the indicated CPT/HCPCS code

Remaining Deductible

The remaining deductible amount associated with the indicated CPT/HCPCS code

Co-insurance

The patient's portion of responsibility for the indicated CPT/HCPCS code, represented as a percentage

Print Option

For a hardcopy record of the patient's preventive service history, click the Print icon.  Doing this will generate a complete copy identifying the patient's name and date of birth in the header.

Print option

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Medicare Advantage

The "Medicare Advantage" sub-tab provides information regarding the beneficiary's enrollment under Medicare Advantage (MA) Managed Care Plans (commonly referred to as Part C contracts) that provide Part A and B benefits for beneficiaries.

NOTE: Whenever myCGS indicates that a beneficiary has coverage through a non-Medicare entity (MA or Medicare Drug Benefit plans), the inquiring provider should always contact the non-Medicare entity for complete beneficiary entitlement information.

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The table below describes the "Medicare Advantage" sub-tab fields:

Field Name Description

Enrollment Date

The date that indicates the start of enrollment to the coverage plan

Termination Date

The date that indicates the termination of enrollment to the coverage. No date in this field means the plan enrollment has not terminated.

Contract Name

A descriptive name of the beneficiary's insurance coverage organization

Plan Name

The name of the actual Medicare Advantage plan

Contract Number

The contract number (if on file)

Address

The coverage plan's address line 1

Phone Number

The coverage plan's contract telephone number (if on file)

Address 2

The coverage plan's address line 2

City

The coverage plan's city

State

The coverage plan's state

ZIP Code

The coverage plan's ZIP code

Website

The coverage plan's website address that will provide information on the beneficiary's insurance

Plan Benefit Package ID

Identification number/code of the benefit package.

Bill Code

The bill code of the plan type. This field only applies to plan types HM, HN, IN, PR, and PS.

Medicare Beneficiary "locked in" to MA
A - Fiscal Intermediary should process all claims
B - MA should process only in-plan Part A claims and in-area Part B claims
C - MA should process all claims

Medicare Beneficiary NOT "locked in" to MA
1 - Fiscal Intermediary should process all claims
2 - MA should process only in-plan Part A claims and in-area Part B claims

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Prescription Drug Program (PDP)

The "PDP" sub-tab provides information on a beneficiary’s Part D prescription drug coverage.

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The table below describes the “PDP” sub-tab fields:

Field Name Description

Enrollment Date

The date that indicates the start of enrollment to the PDP.

Termination Date

The date that indicates the termination of enrollment to the PDP. No date in this field means the PDP enrollment has not terminated.

Contract Name

A descriptive name of the beneficiary’s PDP coverage organization

Plan Name

The name of the actual PDP.

Contract Number

The contract number (if on file)

Address

The coverage plan’s address line 1

Phone Number

The coverage plan’s contract telephone number (if on file)

Address 2

The coverage plan’s address line 2

City

The coverage plan’s city

State

The coverage plan’s state

ZIP Code

The coverage plan’s ZIP code

Website

The coverage plan’s website address that will provide information on the beneficiary’s insurance

Drug Plan

Code identifying the PCP

Plan Benefit Package ID

Identification number/code of the benefit package.

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MSP

The "MSP" sub-tab is populated if the beneficiary has a payer that process claims primary to Medicare. This sub-tab displays only active MSP data and will not be listed if there is no MSP data or if notification of coverage primary to Medicare has not been received by CMS.

NOTE: If a date range is entered on the "Inquiry" screen, it will affect the MSP data returned.

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The table below describes the "MSP" sub-tab fields:

Field Name Description

Maintenance Date

The date maintenance was last performed on the record

Patient Relationship

Identifies if the patient is the actual insured

Group Number

Identifies the MSP Insurance Group Number or the MSP Date of Loss.

  • If the returned value is a series of zeroes, the group number is not available
  • If number begins with ‘DOL’ this is the Date of Loss.

Policy Number

The primary insuring organization's policy number for the Medicare beneficiary

Effective Date

The start date of the primary insurer's coverage

Termination Date

The termination date of the primary insurer's coverage. No date in this field means primary insurance coverage has not terminated.

Type of Primary Insurance

12 = Medicare Secondary – Working aged beneficiary or spouse with employer group health plan
13 = Medicare Secondary – End-stage Renal Disease beneficiary in the 12-month coordination period with an employer group health plan
14 = Medicare Secondary – No-Fault insurance, including auto is primary
15 = Medicare Secondary – Workers' Compensation
16 = Medicare Secondary – Public Health Service (PHS) or other Federal Agency
41 = Medicare Secondary – Black Lung
42 = Medicare Secondary – Veteran's Administration
43 = Medicare Secondary – Disabled beneficiary under age 65 with large group health plan
47 = Medicare Secondary – Other liability insurance is primary
WC = Workers' Compensation Medicare Set-aside Arrangement

Diagnosis Codes

Lists specific diagnosis codes associated with MSP insurance types, such as Workers' Compensation (WC), automobile, and liability situations. If the patient has MSP records based on diagnoses, the specific ICD-10 codes will display for your reference.

Address

The address line 1 of the insurance company

Address 2

The address line 2 of the insurance company

City

The city of the insurance company

State

The state of the insurance company

ZIP Code

The ZIP code of the insurance company

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Hospice/Home Health

The Home Health Care section provides information for each episode start and end date and the corresponding billing activity dates.

The Hospice section provides eligibility information when the hospice benefit is effective and when it terminates, in addition to the total hospice occurrence count for the listed beneficiary.

If the patient has any gap in their episode of care or changes providers at any time, or if their hospice provider has sent the final claim revoking hospice care, you will see more than just a single effective date being returned. Once the final claim has been submitted, the hospice termination (or revocation) date is returned, along with the revocation code. If the patient is still in hospice care, but has changed providers, the start and termination date with each provider will be returned. Therefore, if no termination date is returned, it is to be assumed that the patient is still under hospice care, as no claim has yet been processed that revokes that period of care.

NOTE: The "Hospice/Home Health" sub-tab displays hospice and/or home health data and will not be accessible when there have been no claims received by CMS indicating hospice or home health coverage is active and is in effect per the date(s) requested. To make sure you see all the information, enter a date range in the inquiry screen.

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The tables below describe the "Home Health/Hospice" sub-tab fields:

Home Health Care

Field Name Description

Patient Status

Notes whether the patient is actively receiving services

NOA Indicator

Starting January 1, 2022, Medicare requires Home Health Agencies (HHAs) to submit a one-time Notice of Admission (NOA) instead of Requests for Anticipated Payment (RAPs). myCGS displays:

  • NOA received without condition code 47
  • NOA received with condition code 47

HHEH Start Date

The date the 60-day home health episode period started

HHEH End Date

The date that the home health episode terminated

HHEH DOEBA Date

The date of earliest billing activity for spell of illness

HHEH DOLBA Date

The date of latest billing activity for spell of illness

Provider Number

The NPI of the home health facility

Provider Number Type

A display of "NPI" depending on the source of the provider number

Contractor Number

A display of the Medicare contractor number

Contractor Name

The name of the Medicare contractor

HH Certification Start Date

The date the beneficiary was certified to receive home health care services

HH Recertification Start Date

The date the beneficiary was recertified to continue receiving home health care services

Hospice

Field Name Description

Effective Date

The start date of a beneficiary's elected period of hospice coverage

Term Date

The termination date of a beneficiary's elected period of hospice coverage. No date in this field means the beneficiary's elected period of hospice coverage has not terminated.

Start Date (DOEBA)

Date of Earliest Billing Activity

End Date (DOLBA)

Date of Latest Billing Activity

Days Used

The number of Hospice days used

Provider Number

The NPI of the hospice facility

Type

A display of "NPI" as the type of provider number

Notices of Election (NOE)

The Notice of Election (NOE) is to be submitted within 5 days after a hospice admission in order to be considered timely.

  • The election receipt date, NPI, and revocation code are listed here, if applicable.

Revocation Code

The code indicating the revocation status for the spell listed

Medicare Beneficiary in Hospice Care
0 - Not revoked, open spell

Medicare Beneficiary with Hospice Care Revoked
1 - Revoked by notice of revocation
2 - Revoked by notice of revocation with a non-payment code of "N" and an occurrence code of "42"
3 - Revoked by a hospice claim with an occurrence code of "23"

Election Revocation Date

The date the spell revoked

myCGS will display up to 50 billed Hospice episodes that occurred in the last four years.

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Inpatient

The "Inpatient" sub-tab includes Inpatient, Skilled Nursing Facility (SNF), and Psychiatric Benefit Data sections. The Inpatient section provides hospital inpatient benefit and billing information. The SNF section provides SNF benefit and billing information.

NOTE: While the Psychiatric Benefit Data section now displays in myCGS, the data is not yet available in CMS' HIPAA Eligibility Transaction System (HETS) 270/271 system that we are required to access for eligibility.

The system will return hospital inpatient default deductibles based on the requested start year when the following occurs:

  • No inpatient spell data returned from the database overlaps or falls within 60 days of the requested date (range)
  • Entitlement period and request date period overlap
  • Part A entitlement start year is less than the requested start year

In addition, the system will continue to return the hospital inpatient default deductible remaining amounts, inpatient co-payment days, and SNF co-payment days based on the beneficiary's Part A entitlement start year when the following occurs:

  • No inpatient spell data returned from the database overlaps or falls within 60 days of the requested date (range)
  • Entitlement period and request date period overlap
  • Part A entitlement start year is less than or equal to the requested start year

NOTE: Depending on the date(s) range requested, multiple inpatient and SNF spells might be displayed. The data returned on this screen is directly impacted by timely submission of claims by the provider. The data returned is compiled from claims that have been processed by the Common Working File (CWF). To make sure you see all the information, enter a date range in the inquiry screen.

If a single hospital inpatient/SNF spell spans more than one calendar year, myCGS will return the daily co-payment amounts associated with the beginning year of the spell.

If there is no hospital inpatient/SNF spell within 60 days of the requested date(s) of service, myCGS will return default values for Part A spell data.

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The table below describes the "Inpatient" sub-tab fields:

Part A Deductible

Field Name Description

Start/End Date

The beginning and end date for the calendar year requested.

Deductible Amount

The Medicare Part A deductible amount applied to each spell of illness that occurs during the calendar year.

Inpatient Spell of Illness Detail

Field Name Description

Start Date (DOEBA)

The date of earliest billing activity for the spell of illness

End Date (DOLBA)

The date of latest billing activity for the spell of illness

Billing NPI

The billing NPI of the hospital and/or SNF.  You may refer to the NPPES NPI RegistryExternal website to find the facility's contact information.

Type

Displays the type of provider identified in the Billing NPI field

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Days Allowed

Identifies the number full and co-insurance days allowed for hospital, skilled nursing facility (SNF), Lifetime Reserve, and Lifetime Inpatient Psychiatric Hospital based upon the calendar year requested. The co-insurance amounts are displayed for each, as well.

Days Remaining

Field Name Description

DOEBA

The date of earliest billing activity for the spell of illness

DOLBA

The date of latest billing activity for the spell of illness

Full Days

The number of inpatient full days allowed for the calendar year requested

Co-insurance Days

The number of inpatient full co-insurance days allowed for the calendar year requested

Billing NPI

The billing NPI of the hospital and/or SNF. You may refer to the NPPES NPI Registry to find the facility’s contact information.

Part A Free Services

Field Name Description

STC Codes

The Health Care Service Type Codes (STC) identify classifications of services or benefits. For definitions of the two-digit codes, view the link for "List of STC Codes."

Value

The patient's portion of responsibility for a benefit, represented as a percentage

Start/End Date

The start and end dates of the benefit period

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QMB

Beneficiaries who are enrolled in the Qualified Medicare Beneficiary (QMB) program are dually eligible for both Medicare and Medicaid. Those enrolled in this State Medicaid benefit, which assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing (deductibles, co-insurance/co-pays), are not liable financially.

QMB status may fluctuate for a minority of beneficiaries. If eligibility results indicate the beneficiary QMB enrollment has terminated, please verify the patient's QMB status through online State Medicaid eligibility systems or other documentation, including Medicaid identification cards and documents issued by the state proving the patient qualifies for the QMB program.

The "QMB" sub-tab includes Medicaid Enrollment, Part A Deductible, Inpatient, Skilled Nursing Facility (SNF), Part B Deductible, and Part B Co-Insurance sections.

NOTE: "$0" will display in the deductible, co-insurance, and co-pay sections for beneficiaries enrolled in the QMB program.

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All Screens

For your convenience, this sub-tab combines all of the information from the other sub-tabs, allowing you to scroll through the data much faster.

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