Eligibility Benefits

Available For: Part A, Part B, DME

This inquiry allows users to view a beneficiary's Medicare eligibility: Part A, Part B, Health Maintenance Organization (HMO) and Managed Care Organization (MCO), Medicare Secondary Payer (MSP), Home Health, Hospice, End Stage Renal Disease (ESRD), Preventive Services and Medicare Diabetes Prevention Program (MDPP).

The HIPAA Eligibility Transaction System (HETS) is considered the authoritative source for eligibility information provided on NMP.

Inquiry

  • Go to the Eligibility tab on the Main Menu
  • Enter the required Beneficiary Details fields:
    • Medicare Number
    • Last Name
  • Provide at least one of the following:
    • First Name
    • Date of Birth

Note: The First and Last name must match the beneficiary's Medicare card.

Tip The Medicare Number field will accept either a Health Insurance Claim Number (HICN) or a Medicare Beneficiary Identifier (MBI) until January 1, 2020.
  • Select one of the date options under Optional Details:
    • 12 months in the past through 4 months in the future
    • Current Date
    • Provide Custom Date Range
      • HETS accepts requests for specific periods up to four years in the past and up to four months in the future based on the current date.
Tip For current deductible amounts, use date options 2 or 3 using the most current date or date range.

Response

If the beneficiary is enrolled as a Qualified Medicare Beneficiary (QMB), a green banner will display letting the user know that the beneficiary is a QMB enrollee for one or more Part B Benefit Periods.

In addition to the QMB banner, there is a "QMB Enrolled" indicator which will indicate "Yes" or "No" if the patient is a QMB enrollee for the Part B Benefit period.

Tip QMBs are not liable for Medicare deductibles, therefore deductible information for QMBs is not provided in NMP. This prevents patient status errors, incorrect billing and financial records. Noridian recommends contacting the patients state Medicaid agency for questions about deductible billing.

Each tab will provide specific information.

Tab Description
Eligibility
  • Part A and B Effective and Termination Dates
  • Entitlement Reason Code
    • 0 - Beneficiary insured due to age OASI (Old-Age and Survivors's Insurance)
    • 1 - Beneficiary insured due to disability
    • 2 - Beneficiary insured due to ESRD
    • 3 - Beneficiary insured due to disability and current ESRD
  • Part B Coinsurance
  • Ineligible Period
  • Beneficiary Address
  • Occupational, Physical and Speech Therapy Information
  • Blood Deductible
  • Part D Enrollment Data
HMO/MA
  • Insurer Name
  • Policy Number
  • Effective and Termination Date
  • MCO Plan Type
  • MCO Bill Option Code
  • Address
  • Phone Number
  • Contract Web Site
MSP
  • Insurer Name
  • Policy Number
  • MSP Diagnosis Code
  • Effective and Termination Date
  • Insurer Type
  • Address
HHEH
  • Payer Name
  • Payer ID
  • Payer Number
  • Episode Start and End Date
  • Earliest and Latest Billing Date
  • Patient Status Code and Description
Hospice
  • Date of Earliest and Latest Billing Activity
  • Provider Number
  • Episode Effective and Termination Date
  • Number of Days used in this billed Episode
  • Revocation Indicator
Hospital/SNF Inpatient SNF Hospital Summary
Each table will display a summary of the Earliest and Latest Billing Dates with the following information:
  • Location
  • Billing NPI
  • Admit Date
  • End Date
  • Discharge Status Code and Description
SNF
  • Earliest and Latest Billing Date
  • Days Remaining
  • Co-Payment Information
ESRD
  • Effective Date
  • Benefit Type
Preventive Services
  • Smoking Cessation Benefit Information
  • Pulmonary, Cardiac and Intensive Cardiac Rehabilitation Services
  • Acupuncture Services
  • COVID-19 Vaccine Eligibility (Yes or No)
  • Preventive Services HCPCS Code/Description and Next Eligible Date
MDPP
  • MDPP Active Period
  • MDPP Inactive Period
  • MDPP Deductible Period
  • MDPP Coinsurance Period

 

Preventive Service CPT/HCPCS: 76706, 76977, 77067, 77078, 77080, 77081, 80061, 81528, 82270, 82465, 82947, 82950, 82951, 83718, 84478, 90670, 90732, G0101, G0102, G0103, G0104, G0105, G0106, G0117, G0118, G0120, G0121, G0123, G0130, G0143, G0144, G0145, G0147, G0148, G0297, G0328, G0402, G0403, G0404, G0405, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0472, G0473, G0475, G0476, P3000, Q0091

Note: HCPCS codes 90670 and 90732 (Pneumococcal Vaccines) will display up to 10 previous dates of service and the rendering NPI. These codes will only be viewable if the beneficiary has Medicare Part B coverage.

COVID-19 Immunization Data will display the HCPCS Code and Description, Previous Dates of Service and the rendering NPI if the beneficiary has received a COVID-19 vaccine.

 

Last Updated Wed, 02 Jun 2021 17:55:30 +0000