|
|
Print |
Bookmark |
Font Size:
+ |
–
ELGA-ELGH Key Fields
| Page # |
Important Fields |
Reason |
| Page 1 |
CORRECT CN, NM, IT, DB, SX |
Provides correct Medicare number, name, date of birth and sex code
if entered incorrectly. |
| A-ENT, A-TRM, B-ENT, B-TRM, DOD |
Ensure beneficiary entitlement to Medicare Part A &/or Part B.
Ensure services are not after date of death. |
| FULL-NAME |
Verify the correct spelling of the patient's last name and
first name. |
| PT TBM, OT TBM |
Verify dollar amount of PT and SLP, and OT caps remaining for current
year. |
| Page 3 |
START DATE, END DATE, INTER NUM, PROV NUM, PAT STAT |
Indicates start and end date, intermediary number, provider number,
and patient status at end of two most recent home health episodes.
For prior home health episodes, enter a prior date in the APP DATE
field. |
| Page 4 |
MSP CODE, EFF DATE, TRM DATE |
Verify if beneficiary has insurance primary to Medicare, the type
and the effective and termination dates. |
| Page 5 |
PLAN-TYPE, PLAN-ID, OPT, ENR-DATE, TRM-DATE |
Verify whether the Medicare Advantage plan type and number, the OPT
code and the enrollment and termination dates. |
| Page 9 |
START DATE, TERM DATE, PROVIDER NO, INTER NO, REVOC IND |
Start and term date, provider number, intermediary number, and revocation
indicator for 5 most recent hospice benefit periods (if APP DATE blank)
or 5 most recent hospice benefit periods with TERM DATE on/before APP
DATE. |
| Page 11 |
HCPCS, FROM DT |
Indicates physician billing of a Part B claim for Certification of
HH Plan of Care. Use with ELGH Page 03 and ELGA Page 04. |
|