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April 25, 2016

General or Claims Specific Questions When Calling the Provider Contact Center

To protect the privacy of Medicare beneficiaries and providers, Medicare Administrative Contractors (MACs), like CGS, are required to authenticate certain elements before releasing beneficiary-specific information. When calling the CGS Provider Contact Center (PCC), the Customer Service Representative (CSR) will ask if you have a general question, or a claim specific question. General questions do not require authentication; therefore, this allows the CSR to determine whether they can bypass the authentication process.

General questions are those that do not require the CSR to access the claims processing system (Fiscal Intermediary Standard System (FISS)), or eligibility systems (ELGA/ELGH). Claims specific questions are those that do require the CSR to access FISS, or ELGA/ELGH.

NOTE: General questions about a beneficiary's Medicare eligibility can often be answered through the Interactive Voice Response (IVR) system and the CGS Web Portal, myCGS. CSRs will refer providers back to the IVR if they have eligibility or claim status questions. However, CSRs may be able to assist with more detailed eligibility questions pertaining to Medicare Secondary Payer (MSP) or Health Maintenance Organizations (HMOs), etc.

Please refer to the following table as a guide in determining if your question is general or claim specific.

General Question Claim Specific Question
Examples include, but are not limited to:
  • How to read a remittance advice;
  • How to find information on the CGS or the CMS website;
  • Benefit guidelines;
  • Questions about coverage (not related to a specific beneficiary); or
  • Requesting a mailing address or telephone number.
  • Medicare eligibility information;
  • Claim information (pending/processed);
  • Preventive Services – Next Eligible date; or
  • Overlapping claim information.

Claim –specific/eligibility questions require the CSR to authenticate the following elements:

  • Provider National Provider Identifier (NPI), Provider Transaction Access Number (PTAN) and the last five digits of their Tax Identification Number (TIN).
  • Beneficiary's health insurance claim number (HICN), the first six letters of the beneficiary's last name, the first letter of the beneficiary's first name, and their date of birth.

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