** Program Sponsors – We strongly encourage you to forward this message to your office managers, billing/coding and administrative staff. **
Checking Medicare Eligibility
Checking Medicare eligibility is an important step in the billing process; you can confirm your patient’s benefits and prepare accurate claims. It’s possible your patient doesn’t know he/she is dually eligible, and enrolled, in both Medicare and Medicaid.
You must have the following information to check eligibility for your patient:
- Medicare Beneficiary Identifier (MBI or Medicare number)
- First name
- Last name
- Date of birth
If your patient has Medicare coverage but doesn’t have a Medicare card, encourage your patient to log into mymedicare.gov or call 1-800-MEDICARE (or 1-800-833-4455 if your patient gets benefits under the Railroad Retirement Board) to get a replacement Medicare card.
You can check your patients' Medicare eligibility in one of three ways:
- Your vendor or clearinghouse can give you access to eligibility information for Medicare and other payers
- Your IT department may be able to access eligibility information directly from CMS through the HIPAA Eligibility Transaction System (HETS)
- Your Medicare Administrative Contractor’s (MAC’s) portal and Interactive Voice Response systems provides eligibility information
You will get eligibility information if your patient is entitled to Part A and/or Part B, including information like:
- Medicare beneficiary demographics
- Part A and B entitlement, including any periods of inactivity
- Coverage status of requested and supported Service Type Codes
- Medicare Secondary Payer, Medicare Advantage, and Part D plan enrollment information (where applicable)
- Deductible remaining
If you already check eligibility electronically for another payer, work with your vendor to get access to Medicare information.
Read the OTP Medicare Billing & Payment Fact Sheet for more information on billing Medicare for OTP services.
New Frequently Asked Questions (FAQs)
We continue to update the FAQs on our webpage. Look for the **NEW** designation to easily find the latest information.