- Select View Attachments to download the Patient Eligibility Flow Chart.
The Centers for Medicare & Medicaid Services (CMS) advises provider contractors in Publication 100-09 (Medicare Contractor Beneficiary and Provider Communications Manual) Chapter 6, Section 50.1, that 'Providers shall be required to use IVRs to access claim status and beneficiary eligibility information.' By using the IVR, representatives will be freed to spend time with providers on more difficult claims issues.
Patient eligibility information is available, via the IVR, between the hours of 6:00 a.m. and 9:00 p.m. by calling 1-866-238-9654. If you have a rotary dial telephone you will not be able to utilize the IVR. You should contact the SC Provider Contact Center (PCC) at 1-888-828-2092 to speak with a Customer Service Representative (CSR). CSRs are available to assist you from 8:30 a.m. through 4:30 p.m., Monday through Friday except on pre-announced closing dates.
What type of patient eligibility information can be obtained from the IVR?
- Current Medicare Part B effective and termination dates
- A status of the current year's deductible (Satisfied or Unsatisfied)
- Medicare Advantage Plan Enrollment Status (Sometimes referred to as HMO)
Please note: At the beginning of each new calendar year, deductible information will not be available until the initial claims submitted for the new year have processed and finalized in the system.
Once you have used the IVR for eligibility and/or deductible information, you may discover you need to obtain more complex information from a CSR. Examples of information that can only be obtained from a CSR are:
- Medicare Secondary Payer (MSP) status;
- Name of the Medicare Advantage (MA) Plan;
- Hospice, home health, or Part A benefit periods;
- Eligibility dates for preventative services; and
- Outpatient therapy caps.
TIPS before dialing: To save time, please have the following information available when starting your call:
- Your National Provider Identification (NPI) number.
- Your Provider Transaction Access Number (PTAN), formally known as the Provider Identification Number (PIN);
- The patient's Health Insurance Claim (HIC) number;
- The patient's name, as it appears on their Medicare card; and
- The patient's date of birth.