Eligibility FAQs
Q: How can I ensure that beneficiary identification information submitted on my claims matches the information on file for the patient?
A: It is critical that beneficiary identification information submitted on claims is identical to the information found on the beneficiary’s most recent Medicare card. Make a copy of the Medicare card for your records.
Use the beneficiary’s Medicare card to verify the following:
• Medicare number -- Verify the beneficiary’s Health Insurance Claim (HIC) number, ensuring it has not been changed.
• Beneficiary’s name -- Verify the beneficiary’s name indicated on your claim is exactly as it reads on their Medicare card. For example, do not indicate “Betty” if the card reads “Elizabeth.”
• Effective date -- Verify the effective date of coverage.
• Date of birth -- Verify the beneficiary’s date of birth. Be careful not to transpose numbers, especially when entering HIC numbers.
• Part A and/or Part B -- Verify which part of the Medicare program the beneficiary is enrolled, either A or B or both.
• Eligibility dates -- Current and previous dates of service eligibility can be verified by using the Interactive Voice Response Unit (IVR). Call the First Coast Service Options Part B IVR at (877) 847-4992. Refer to the Part B IVR Operating Guide for instructions.
(Last Modified 11/07/08)
Source: CMS IOM Pub 100-09, Chapter 6, Section 50.1 (http://www.cms.hhs.gov/manuals/downloads/com109c06.pdf 
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)A: It is recommended you obtain eligibility and benefit information prior to rendering services to patients. You can also do the following:
• Ask patients if they have recently enrolled in any new health insurance plans.
• Request to see a copy of all of their health insurance cards.
• Contact the Interactive Voice Response Unit (IVR) to obtain Medicare Advantage (MA) plan (formerly HMO) information, deductible, and Medicare Secondary Payer (MSP) information. Eligibility information is available Monday through Friday, from 6:00 AM-6:00 PM (Eastern and Central Time Zones) by calling the Part B IVR at 1-877-847-4992. Refer to the Part B IVR Operating Guide for instructions.
• You may also use the IVR 24 hours a day to receive other general Medicare information. As an added convenience, the FCSO IVR allows users to interact with the IVR using Speech Recognition.
(Last Modified 11/07/08)
Source: CMS IOM Pub 100-09, Chapter 6, Section 50.1 (http://www.cms.hhs.gov/manuals/downloads/com109c06.pdf )
)Q: How can I avoid claim denial(s) due to charges being incurred during a period when the patient is not eligible for Medicare?
A: Multiple steps can be taken to verify a patient is entitled to Medicare when services are provided:
• Obtain a copy of the patient’s most recently issued Medicare card:
• To ensure accuracy, compare this number with the one submitted to Medicare
• Verify for which part(s) of Medicare the patient is eligible
• Verify the dates of eligibility
• Check current and previous dates of eligibility for beneficiaries using the Interactive Voice Response (IVR) system. Call (877) 847-4992; from the main menu, press “3,” then “1” (current eligibility).
• Refer to the Part B IVR Operating Guide for additional instructions.
(Last Modified 11/05/08)
Part B IVR Operating guide; CMS Internet Only Manual (IOM), Publication 100-09 Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 3, Sections 20.1 (B), 20.1.2, 30.3.3; Chapter 6, Sections 50.1 & 80.3.3
A: Providers are required to contact the Part B Interactive Voice Response unit (IVR) at 1-877-847-4992 to access claim status and beneficiary eligibility information. Instructions on how to use the IVR can be found in the “IVR Operating Guide – Part B.”
(Last Modified 10/02/08)
Source: CMS IOM Pub 100-09, Chapter 6, Section 50.1 (http://www.cms.hhs.gov/manuals/downloads/com109c06.pdf 
)
)Q. For a patient who is not enrolled in traditional Medicare Part B but is enrolled in a Medicare replacement, can a participating Part B provider ask for payment at the time of service (at the standard Florida Medicare fee schedule rate) and instruct the patient to file the claim with the Medicare replacement for direct reimbursement?
Regarding traditional Medicare vs. HMO, what fee schedule can we bill?
Regarding traditional Medicare vs. HMO, what fee schedule can we bill?
A. When a patient, who is enrolled in a Managed Care Plan (MCP), uses out-of-network providers, their out of pocket expenses for covered services may be higher. It is important to verify with the patient (and confirm through FCSO’s Part B Interactive Voice Response unit [IVR] at 1-877-847-4992) if the patient is enrolled in an MCP.
If the patient is enrolled in an MCP, contact the MCP prior to rendering services to determine what amount he or she is responsible for paying out of pocket. This information will provide you with guidance on whether to treat and bill the patient. Medicare does, however, limit the amount providers can bill patients for services.
The CMS Managed Care Manual, Publication 100-16, Chapter 4, Section 10.2 - Services of non-contracting providers states:
• Medicare Advantage (MA) MCPs must reimburse non par providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non par provider when the patient is out of the service area.
Chapter 6 further states:
• Non contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).
There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if an MA enrollee seeks care outside of the MA plan in which he/she is enrolled and the MAO sponsoring the MA plan has no legal liability for reimbursement, then yes, the provider can bill the MA enrollee. The provider should not bill the MA enrollee more than the original Medicare amount for what would otherwise be covered A/B services.
There is no specific guidance for collecting payment from the patient at the time services are rendered.
(Last Modified 10/02/08)
Source: Medicare & You 2008: Overview: Traditional and Managed Care Plans (http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf ; CMS IOM Pub 100-16 Medicare Managed Care Manual, Chapter 4 (http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf ) & Chapter 13 (http://www.cms.hhs.gov/manuals/downloads/mc86c13.pdf ); CMS IOM Pub 100-16 Medicare Managed Care Manual, Chapter 6, Section 100 – Non-contracted providers (http://www.cms.hhs.gov/manuals/downloads/mc86c06.pdf )
; CMS IOM Pub 100-16 Medicare Managed Care Manual, Chapter 4 (http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf ) & Chapter 13 (http://www.cms.hhs.gov/manuals/downloads/mc86c13.pdf ); CMS IOM Pub 100-16 Medicare Managed Care Manual, Chapter 6, Section 100 – Non-contracted providers (http://www.cms.hhs.gov/manuals/downloads/mc86c06.pdf )