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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.

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