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.
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) benefit
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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