Eligibility Report Data

Common patient information is displayed in the Subscriber/Dependent section (i.e. Name, Gender, Address, Date of Birth, HIC/Policy # ).

 

This section displays specific information related to eligibility and coverage for the patient.

As highlighted in the two sample images to the right, different components of data are included in this section depending on whether the payor is Medicare or not.

 

Eligibility and Coverage Report Items (MEDICARE)

●     Part A Effective Date — Indicates the start of eligibility for Medicare Part A benefits.

●     Part A Termination Date — Indicates the termination of eligibility for Medicare Part A Benefits. No date in this field means Medicare Part A eligibility has not terminated.

●     Part B Effective Date — Indicates the start of eligibility for Medicare Part B benefits.

●     Part B Termination Date — Indicates the termination of eligibility for Medicare Part B benefits. No date in this field means Medicare Part B eligibility has not terminated.

●     ESRD Effective Date — Indicates the start of eligibility for ESRD services.

●     ESRD Benefit Desc. Svc Type Code — Type of Dialysis (14 or 15) services that are being rendered.  

●     ESRD Transplant DC Date — Date the transplant services were discharged.

 

Eligibility and Coverage Report Items (NON-MEDICARE)

●     Effective Date — Indicates the beginning date of the insurance plan.

●     Termination Date — Indicates the end date of the insurance plan.

●     Plan Number — Number assigned to the patient’s insurance plan.

●     Group Number — Group number assigned to the insurance plan.

●     Subscriber ID — ID number assigned to the insurance plan for the patient.  

●     Benefit Coverage Date — Lists the specific services that are included in the insurance plan.

●     Coverage Dates — Date range of medical care coverage for the patient.

 

If available, this section displays any information associated with the secondary payor.

 

Medicare Secondary Payor Report Items

●     Effective Date — The date that indicates the start of the primary insurer’s coverage.

●     Termination Date — The date that indicates the termination of the primary insurer’s coverage. No date in this field means primary insurance coverage has not terminated.

●     Insurer Name — Name of the insurance company.

●     Address — Address line of the insurance company (Street, City, State, Zipcode).

●     Policy Number — The primary insuring organization’s policy number for the Medicare beneficiary.

●     Type of Primary Insur — The type code and description of the Primary Insurance Plan:

o     12 — Medicare Secondary Working Aged Beneficiary or spouse with Employer group health care plan

o     13 — Medicare Secondary End Stage Renal Disease Beneficiary in the 12 month coordination period with and Employer group health plan

o     14 — Medicare Secondary No-Fault insurance including auto is primary

o     15 — Medicare Secondary Workers Compensation

o     16 — Medicare Secondary Public Health Service or other Federal Agency

o     41 — Medicare Secondary Black Lung

o     42 — Medicare Secondary Veteran’s Administration

o     43 — Medicare Secondary Disabled Beneficiary under age 65 with Large Group Health Plan

o     47 — Medicare Secondary other liability insurance is primary

o     WC — Workers Compensation Medicare Set aside arrangement

 

This section displays details for any Home Health certifications associated with the patient (if applicable).

 

Home Health Certification Report Items

●     Certification —HCPCS code used when the subscriber became certified for home health services.

●     Certification Date — Date the subscriber was certified to receive home health services.

●     Re-Certification — HCPCS code used when beneficiary became recertified for home health services.

●     Re-Certification Date — Date the beneficiary was recertified to receive home health services.  

 

This section displays specific information that is related to home health care services that the patient has received (if applicable).

 

Home Health Report Items

●     Start Date — The date the 60-day home health episode period started.

●     End Date — The date that the home health episode terminated.

●     DOEBA Date — The date of earliest billing activity for spell of illness.

●     DOLBA Date — The date of latest billing activity for spell of illness.

●     NPI # — NPI number assigned to the corresponding home health agency.

●     Name — Displays the name of the home health agency that conducted services.

 

This section displays specific information that is related to hospice health care services that the patient has received (if applicable).

 

Hospice Report Items

●     Period — Number of the benefit period.

●     F2F — Indicates if a Face to Face is required for the benefit period. For benefit periods that occur after the third period, the word “Req” will display in this column.

●     Start Date — Beginning date of a subscriber’s elected period of hospice coverage.

●     End Date — Ending date of a beneficiary’s elected hospice coverage. No date in this field means the beneficiary’s elected period of hospice coverage has not terminated.

●     Revocation Code — Code indicating whether hospice coverage was terminated or not. “0” indicates continuing hospice coverage. “1”, “2”, or “3” indicates the hospice coverage was terminated (revoked). An explanation will display with the code.

 

●     NPI # — NPI number assigned to the corresponding home health agency.

●     Name — Displays the name of the hospice agency that conducted services.

 
 

This section displays any Medicare Advantage information for the patient (if applicable).

As of the 18.6.2 release, all Medicare Advantage plans will display in this section regardless of how plans are identified in the CMS HETS file or whether restrictions apply. When applicable, a "Contact Entity for Eligibility/Benefit Information" message will display at the bottom if a plan contans an "EB=U" identifier.

 

 

This section displays information for any existing pharmacy coverage plans that are associated with the corresponding patient.

 

Pharmacy Report Items

●     Effective Date — Indicates the start of enrollment to the coverage plan.

●     Termination Date — Indicates the end of enrollment to the coverage plan.

●     Contract Number — The insurance company’s contract number.

●     Plan Number — Number of the beneficiary’s pharmacy coverage plan.

●     Plan Name — Name of the beneficiary’s insurance coverage organization.

●     Plan Website — Website address associated with the coverage provider.

●     Plan Address — Mailing address associated with the coverage plan.

●     Plan Phone — Telephone number associated with the coverage plan.

●     Parts D — Indicates if the plan is a Part D pharmacy plan.

 

If available, the Reserve section will display any details that are related to insurance reserve information for the corresponding patient.

 

If available, the Restrictions section will display specific information for any existing health care restrictions associated with the corresponding patient, as shown in the sample image below.

 

The Patient Responsibility section outlines any current health care charges that are associated with the corresponding patient, along with general details that are associated with each charge (i.e. Insurance, Type, Coverage Level, Service Type, Amount/Qty, and any Contact Info/Notes ).

 

This section will display any other disclaimers, or notices, that are associated with the corresponding patient (if applicable). As shown in the sample image below, several services that are non-covered for the insurance plan are listed in the Disclaimers/Notices section.