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December 3, 2014

Patient Eligibility: Reminders for the New Year

With the new year, your Medicare patients may be making changes in their Medicare and supplemental insurance plans.  Patient eligibility is one of the top reasons Medicare claims are denied, including:

  • The patient’s Medicare Health Insurance Claim (HIC) number and name do not match;
  • The patient’s HIC number is invalid;
  • The patient is not eligible for Medicare Part B; or
  • The patient has elected a Medicare Advantage (MA) Plan instead of traditional Medicare

You can prevent claim denials for patient eligibility by verifying that the patient’s name (including spelling) and Medicare number are correct and match the patient’s red, white and blue Medicare card, the type of Medicare plan the patient has elected (fee-for-service or an MA plan), and the patient’s eligibility. We recommend you obtain copies of the patient’s “insurance cards,” including their original Medicare card (even MA plan enrollees have an original Medicare card).

Check eligibility before you submit claims. Options for verifying eligibility include:

  • The CGS Interactive Voice Response (IVR) unit: call 866.290.4036
  • The CGS web portal, myCGS® (you must be registered to use this portal – log in here)
  • Work through a third-party vendor to obtain eligibility through HETS 270/271 transactionsExternal Website

Refer to the CMS websiteExternal Website for more information regarding MA plans.

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