Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility

30.6 - Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility Data (Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The A/B MAC (A) or (HHH) will allow only Medicare certified providers as defined in §§1861 and 1866(e) of the Social Security Act (the Act) and their billing agents automated access to beneficiary eligibility data. Disclosure of CWF eligibility data is restricted under provisions of the Privacy Act of 1974, 5 U.S.C §552a. Under limited circumstances, the Privacy Act permits CMS to disclose information without consent of the individual. One circumstance is for “routine uses,” that is, disclosure for purposes that are compatible with the purpose for which CMS collects the information. In the case of this provider access, a routine use exists which permits release of data to providers or their authorized billing agents for the purpose of verifying a patient’s eligibility for benefits under the Medicare program. The use of the data by a provider in preparing claims for hospital-based physicians would be an example of unauthorized use because the physicians are not Medicare providers as defined in the Act. A/B MACs (A) or (HHH) will adjust their systems to accept the revised standard HIQA/HUQA records from the CMS CWF. The standard data elements to be made available to providers are listed below: • Medicare beneficiary identifier; • Beneficiary: o Last name (first six positions)/first initial; o Date of birth; o Sex; o Date of death; o Lifetime reserve days remaining; o Lifetime psychiatric days remaining (requesting hospital must use a psychiatric provider number to obtain this data); o Cross reference Medicare beneficiary identifier; o Current and prior A and B entitlements, with start and stop dates for Part A, Part B, ESRD, HMO, and hospice; and o Spell of illness (applicable spell based on the date entered by the provider and the next most recent spell): • Hospital full days remaining; • Hospital coinsurance days remaining; • SNF full days remaining; • SNF coinsurance days remaining; • Part A cash deductible remaining to be met; • Date of earliest billing action for indicated spell-of-illness; • Date of latest billing action for indicated spell-of-illness; • Blood deductible (combined annual Part A and B remaining to be met for applicable year entered by provider); • Part B trailer year (applicable year based on date entered by provider); • Part B cash deductible; • Physical therapy/speech-language pathology limit (physical therapy and speech-language pathology are applicable to physical therapy limit); • Occupational therapy limit; • Hospice data (applicable periods based on the date entered by the provider and the next most recent period); • ESRD indicator (shows beneficiary is currently entitled); • REP payee indicator; • MSP indicator; • Home Health Benefit Period: o Part A visits remaining; o Part B visits applied; o Date of earliest billing action for home health benefit period; o Date of latest billing action for home health benefit period. • HMO information (applicable periods based on date entered by the provider): o Name; o Identification number; o ZIP Code; o Option code; o Start date; o Termination date; o Pap smear screening risk indicator, professional date, and technical date; o Mammography screening risk indicator (applicable to screening services prior to January 1, 1998), professional date, and technical date; o Colorectal screening (no risk indicator); procedure code, professional date, and technical date; o Pelvic screening risk indicator and professional date; o Pneumococcal pneumonia vaccine (PPV) date; o Influenza virus vaccine date; and o Hepatitis B vaccine date. See Chapter 10 of this manual for a complete discussion of the HIQH (Health Insurance Query for Home Health Agencies). The A/B MAC (A) will make sure that psychiatric information is not being made available to all hospitals. This information is to be made available only to psychiatric hospitals or hospitals that furnish inpatient psychiatric hospital services. Providers may use direct entry terminals or dial-up terminals to inquire about beneficiary eligibility utilization and deductible status. The A/B MAC (A) must use either the HIQA screen display (see §30.6.1.1) or create its own Customer Information Control System (CICS) screens from the HUQA data records (see §§30.6.1.2 and 30.6.1.3). Providers may not have access to any other CWF records, e.g., the health insurance master record (HIMR). The data must be from CWF. The A/B MAC (A) will not substitute local history.