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How to Verify Medicare Coverage: A Provider’s Guide

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Medicare coverage verification is crucial for healthcare providers to ensure compliance and quality patient care.

Whether dealing with Original Medicare, Medicare Advantage Plans, or Prescription Drug Coverage, understanding and completing each verification step can significantly impact your practice’s operational efficiency and patient satisfaction.

This guide will help how providers can effectively verify Medicare coverage, detailing the essential steps and methods available to streamline the process.

What is Medicare Coverage?

Medicare is a federal health insurance program primarily for people aged 65 and older, though it also covers younger individuals with specific disabilities and those with End-Stage Renal Disease. The coverage is divided into several parts, each serving different healthcare needs.

Medicare Advantage Plans

Here’s an overview of Medicare coverage parts

Medicare Part A (Hospital Insurance)

Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and home health care. It is funded by the payroll tax (FICA) deposited into the Hospital Insurance Trust Fund.

Medicare Part B (Medical Insurance)

Medicare Part B covers doctors’ services, outpatient care, medical supplies, and preventive services. It also covers:

  • Diagnostic and laboratory tests, such as X-rays and blood work
  • Medical equipment, such as wheelchairs and hospital beds
  • Orthotics (devices that support joints) and prosthetics (artificial body parts)
  • Mental health care
  • Ambulance services 
  • Preventive benefits and screenings

Part B is financed by Part B premiums (paid monthly by Medicare beneficiaries) and general revenues from the federal government. Medicare Parts A and B are collectively called “Original Medicare.”

Medicare Part C (Medicare Advantage Plans) 

Part C is an alternative way to receive your Medicare benefits. Private companies approved by Medicare offer these plans and provide all Part A and Part B benefits, typically including Part D.

Healthcare providers can get Medicare coverage via original Medicare or through a plan offered by a private company called a Medicare Advantage plan.

If you’re enrolled in a Medicare Advantage plan, you’ll still have Medicare Parts A and B, but you’ll get your healthcare services through a private plan (that you’ll choose). Typically, you will pay the usual Part B premium plus any additional premium the plan may charge. 

💡 To compare and choose the Medicare Plans, click here.

Medicare Part D (Prescription Drug Coverage)

Medicare Part D is the government’s Medicare program but is offered and managed through private insurers like Cigna Healthcare.

This part adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Plans, and Medicare Medical Savings Account Plans.

Part D plans cover costs for various types of prescription drugs, depending on your chosen plan. Part D works with:

  • Original Medicare (Part A and B)
  • Medicare Supplement policies
  • Many Medicare Advantage plans come with some prescription coverage already included.

These parts of Medicare help cover specific services and often have their costs, restrictions, and conditions for coverage. Participants usually pay part of the costs through deductibles for hospital and medical services and small monthly premiums for non-hospital coverage.

What Things A Provider Needs Before Verifying Medicare Coverage Of A Patient?

When a healthcare provider is preparing to verify a patient’s Medicare coverage, they typically need to take several vital pieces of information and steps. This process is crucial to ensure that the services provided will be covered and to determine any out-of-pocket costs for the patient.

Things Needed for Verifying Medicare Coverage

Here’s what a provider usually needs before verifying Medicare coverage:

🗹 Medicare Number

The patient’s Medicare number is essential for accessing their benefits and coverage details. This number is found on the patient’s Medicare card.

🗹 Patient’s Personal Information

This includes the patient’s full name, date of birth, and sometimes the social security number. This information must match the details on the Medicare record to ensure accurate verification.

🗹 Service Date

The date the service is scheduled or was provided. Coverage details might vary based on the date, especially around the start or end of coverage periods.

🗹 Details of the Service or Procedure

Knowing the specific services or procedures to be provided helps determine whether they are covered under the patient’s Medicare plan. This includes diagnostic codes, procedure codes, or treatment plans.

🗹 Provider Information

The healthcare provider’s details include their National Provider Identifier (NPI) and tax identification numbers. This information is necessary to establish that the provider is recognized by Medicare and authorized to claim payments.

🗹 Type of Medicare Plan

Since Medicare coverage can vary significantly between Parts A, B, C (Medicare Advantage), and D, knowing the type of plan the patient is enrolled in is crucial. Each part covers different kinds of services.

🗹 Consent to Verify Coverage

Depending on the healthcare facility’s policy and HIPAA guidelines, written consent from the patient might be required to access their personal and coverage information.

🗹 Access to Medicare’s Eligibility Tools

Providers often use electronic systems such as the Medicare Eligibility Tool or other software provided by Medicare Administrative Contractors (MACs) to check coverage. This requires appropriate access credentials and training on the system.

🗹 Coverage Period Details

It’s essential to check that the patient’s coverage is active on the service date, including any recent changes in their Medicare status.

🗹 Secondary Insurance Information

If the patient has secondary insurance (like Medigap or a private plan), details of this coverage are also needed because it can affect billing processes and out-of-pocket costs.

How to Verify Medicare Coverage?

Providers must verify the coverage carefully to avoid coverage issues. Below are the 6 different methods for Medicare coverage verification. You can follow any method that suits your billing workflows.

Methods to Verify Medicare Coverage

1st Method – Verifying Medicare Coverage via SPOT

SPOT (System for Provider Online Transactions) is a tool that lets you check if a Medicare beneficiary is eligible for benefits. Here’s how to use it:

  1. Get Started: Before offering services, get a copy of the beneficiary’s Medicare card and confirm their insurance details with them or their legal representative.
  2. Access SPOT: First Coast provides SPOT to check both Part A and Part B eligibility and details like preventive services and deductibles.
  3. Check Eligibility:
    • Go to the “Eligibility” option in the top menu.
    • Enter the beneficiary’s details like last name, Medicare ID, and date of birth.
    • Specify the dates for which you need information (you can check up to 4 months in the future and 24 months past).
    • Hit “Search” to get the results.
  4. Review Results: The results will show details like the beneficiary’s name, eligibility dates for Part A and Part B, and other specific benefits information.

💡 One major benefit of using SPOT? You can export the Medicare Coverage results in PDF format to quickly refer to them later or print them out for records.

2nd Method – Using MAC Online Provider Portal

MAC Online Provider Portal Each Medicare Administrative Contractor (MAC) provides an online portal where you can:

  • Register and log in.
  • Enter the beneficiary’s information, such as Medicare ID and date of birth.
  • Access eligibility information in real-time.

3rd Method – Verifying Medicare Eligibility via MAC Phone Verification

You can enter the beneficiary’s HICN or MBI, the beneficiary’s first and last name, and the beneficiary’s date of birth to get the beneficiary’s eligibility information in real-time. This option is self-service, and an MDPP supplier can access its MAC’s automated phone system at nearly any time.

Here’s how to get started:

  • Find the phone number for your MAC.
  • The automated system will ask to input your provider’s I.D. and beneficiary’s details.
  • Get real-time eligibility information.

4th Method – Confirming Medicare Part A Eligibility via IVR

The Interactive Voice Response (IVR) system is available 24/7 (except during maintenance) and helps people get quick access to eligibility and claims status.

Here’s a simplified and user-friendly version of the Part A Medicare verification process for providers:

★ Getting Medicare Part A Coverage Support

Customer Service HoursFlorida and U.S. Virgin Islands – 8 a.m. to 4 p.m., Monday-Friday (Excluding holidays)
Toll-Free Number1-888-664-4112
For Speech and Hearing Impaired1-877-660-1759
Training ClosuresTypically closed for training on Thursdays from 2 p.m. – 4 p.m. E.T.

⇒ IVR Availability

  • 24/7 Access: Available all day, every day, excluding scheduled maintenance.
  • Service Hours for Claims and Eligibility:
  • Monday-Friday: 7 a.m. – 7 p.m. E.T.
  • Saturday: 6 AM – 3 PM ET
  • Closed on Holidays.

⇒ Using the IVR – Tips and Options

Choose between speech or touchtone.

For Speech:

  • Use a telephone with a handset or headset.
  • Avoid speakerphones, cell phones, and noisy environments.
  • Speak clearly in a quiet setting.
  • Use MM/DD/YYYY format for dates.
  • If speech is not recognized, switch to touchtone.

For Touchtone:

  • Enter dates as MM/DD/YY.
  • Use the * key to input letters. Example: To enter “A,” press *21#.
  • Enter up to six letters of the patient’s last name, stopping at special characters.
  • Press # to complete the entry.

⇒ Things Needed at Provider’s End

  • Required for Access: National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), Tax Identification Number (TIN), beneficiary Medicare ID, name, date of birth, and date of service.

⇒ IVR Menu Navigation

  • General Information: Updates, events, and operational hours.
  • Claim Status: Details about submitted and processed claims.
  • Check Status: Information about recent checks.
  • Publication Information: Access to Medicare seminars and publications.
  • Eligibility Information: Confirm beneficiary eligibility and plan details.
  • Remittance Codes: Explanation of codes on remittance advice.
  • Enrollment Information: Application status and enrollment details.
  • Repeat Menu: Return to the main menu.
  • End Call: Exit the IVR system.

5th Method – Confirming Medicare Part B Eligibility via IVR

The Interactive Voice Response (IVR) system is available 24/7 (except during maintenance) and helps people get quick access to eligibility and claims status.

Here’s a simplified and user-friendly version of the Part B IVR Medicare verification process for providers:

★ Getting Medicare Part B Coverage Support

Phone Number1-877-847-4992
(24/7 Availability – except during scheduled maintenance)
Phone Number for Providers in Florida1-866-454-9007
(Available from 8 a.m. to 4 p.m., ET, Monday through Friday – excluding holidays)
Phone Number for Providers in the U.S. Virgin Islands1-866-454-9007
(Available from 8 a.m. to 4 p.m., ET, Monday through Friday – excluding holidays)
For Speech and Hearing Impaired1-877-660-1759

⇒ IVR Options

Providers can choose between speech recognition and touchtone input.

For best results with speech:

  • Use a telephone with a handset or headset.
  • Avoid speaker phones and mobile phones.
  • Avoid loud environments and ensure clear speech.

For touchtone:

  • Enter dates in mm/dd/yy format.
  • Use the * key for alphabetic input, followed by the letter’s key and its position on the key.
  • Enter up to six letters for names with special characters, stopping before the unique character.

⇒ Menu Navigation Tips

Claim Status and Re-openings: Check the status of assigned and non-assigned claims, procedure codes, and more: Press 2

Eligibility Checks: Current, past service dates, and Medicare Advantage details: Press 3

Pending Claims Details: Information on current and historical claims status: Press 4

Check Information: Details on the latest checks and their status: Press 5

Remittance and Pricing: Information on remittance codes and pricing for specific procedure codes: Press 6

Enrollment Queries: Check application statuses and related information: Press 7

Repeat Menu: Return to the main menu: Press 8

End Call: To terminate the call, Press 9

6th Method – Using HETS for Medicare Coverage Verification

HETS (HIPAA Eligibility Transaction System) lets you submit eligibility requests for Medicare beneficiaries online. However, you must set up a HIPAA-compliant tool and integrate it with the HETS to send and receive these transactions.

To find out if a patient is covered, you can send a HETS 270 request. To check their status in HETS, you’ll need:

  • Their Medicare Beneficiary Identifier
  • First and last name
  • Date of birth (mm/dd/yyyy)

If they’re eligible, the 271 response will tell you about their:

  • Part A entitlement
  • Part B entitlement
  • Part D plan
  • Hospital lifetime reserve days left
  • Skilled nursing facility days left

HETS is good for big healthcare places that can build their own systems. It’s quick and secure since you avoid third parties.

💡 Need help with verifying Medicare eligibility status via HETS? Contact here: mcare@cms.hhs.gov OR 1-866-324-7315

Why Do Providers Need Medicare Verification?

Medicare verification is a critical component of healthcare management, helping to ensure operational efficiency, regulatory compliance, financial stability, and high-quality patient care. For providers, staying diligent with Medicare verification is a proactive measure that significantly benefits their practice and patients. Let’s see why Medicare verification is essential for providers.

✅ Eligibility Confirmation

As healthcare providers, verifying a patient’s Medicare coverage is essential to confirm their eligibility for services when they are provided. Medicare eligibility can change for various reasons, such as reaching a certain age, changes in disability status, or other qualifying conditions. Verification at each visit ensures that the provider can offer the right services covered under the patient’s current plan, avoiding any potential legal or financial complications that might arise from providing non-eligible services.

✅ Benefit Details 

Medicare offers different coverage plans, and each plan has specific terms, including which medical services are covered, to what extent, and the patient’s financial responsibility, such as deductibles and copayments in Medicare’s costs for each plan. By verifying these details, providers can tailor their care plans to what is assuredly covered by the patient’s insurance, ensuring that necessary treatments are not omitted and that billing is aligned with coverage, thus avoiding providing services that might not be reimbursed.

✅ Preventing Billing Errors

When a provider has accurate, verified information about a patient’s Medicare coverage, it minimizes the risk of billing errors. This accuracy is crucial for submitting claims correctly on the first attempt, which helps avoid claim denials, delays in payments, and the need for re-submission or corrections. These scenarios can be resource-intensive and costly, so prevention through verification helps maintain financial and operational efficiency.

✅ Compliance with Regulations

Medicare has specific guidelines and regulations that providers must adhere to, including the need for coverage verification. Staying compliant is not just about following rules—it’s also about avoiding penalties, fines, or even potential exclusion from Medicare programs, which can have severe consequences for a provider’s practice.

✅ Financial Predictability and Planning

Financial stability often depends on predictable revenue streams for healthcare providers. By verifying Medicare coverage, providers better understand what services will be reimbursed and can better manage their billing and financial planning. This predictability aids in more effective overall financial management and risk minimization, such as assessing the reasons for exclusion from Medicare’s program and solving the potential issues.

✅ Enhanced Patient Care and Satisfaction

Knowing the exact details of a patient’s Medicare coverage allows providers to make informed decisions about treatment options. This leads to better patient care outcomes, as patients receive appropriate, covered treatments without undue delays or complications. Moreover, when patients are confident that their provider is informed about their coverage, it enhances their overall satisfaction, as they are less likely to encounter unexpected expenses or coverage issues.

Check Medicare Eligibility + Claim Status — Fast & Easy with BMB

The BestMedicalBilling (BMB) verifies Medicare Coverage for healthcare providers to ensure that the services rendered are eligible for Medicare reimbursement.

1. Simply visit BestMedicalBilling.com.

2. Book a free appointment by entering your name, email, and phone number.

3. One of their representatives will get in touch with you immediately. They’ll help check if Medicare covers your patient.

4. Additionally, you may call BMB at 1-888-488-5015 to receive support with Medicare coverage verification.

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Here’s how BMB completes the Medicare coverage verification process for providers:

1. Gather Provider Information

  • Provider Details: Collect all necessary information about the provider, including their National Provider Identifier (NPI), Tax Identification Number (TIN), and specialty.
  • Medicare Enrollment Status: Check if the provider is enrolled in Medicare and verify their enrollment status using tools like the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

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2. Utilize Medicare Verification Tools

  • CMS Systems: Use Centers for Medicare & Medicaid Services (CMS) systems such as the PECOS to check the provider’s Medicare enrollment status.
  • IVR Systems: Use Interactive Voice Response (IVR) systems provided by Medicare Administrative Contractors (MACs) for quick status checks.

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3. Check Provider Credentials

  • Revalidation: Ensure the provider has revalidated their Medicare credentials within the required timeframe.
  • Licensure and Certifications: Verify that the provider holds all necessary state-specific licenses and board certifications relevant to their specialty.

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4. Verify Participation and Opt-Out Status

  • Medicare Participation: Determine if the provider is a participating provider who accepts Medicare assignment (agreement to accept Medicare’s approved amount as full payment).
  • Opt-Out Status: Check if the provider has opted out of Medicare, which means they do not accept Medicare insurance.

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5. Documentation and Compliance

  • Document Verifications: Record all verifications for compliance and auditing purposes.
  • Regular Updates: Regularly update and re-verify provider information to maintain current and accurate status in billing systems.

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6. Integration with Billing Software

  • Software Integration: Integrate these verifications into medical billing software like MediFusion to streamline claims processing and reduce denials for issues related to provider eligibility.

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7. Monitor and Respond to Changes

  • Ongoing Monitoring: Regularly monitor changes in Medicare policies and provider status to adjust billing practices accordingly.
  • Feedback Loop: Establish a feedback loop between billing specialists and providers to address any issues related to Medicare coverage verification promptly.

Conclusion

Verifying Medicare coverage is more than a procedural task—it is an essential requirement of a healthcare provider’s operations that ensures financial stability, compliance, and high-quality patient care. Healthcare providers must complete Medicare coverage verification for their patients for smooth billing operations. They should understand the way and utilize tools like SPOT, IVR systems, and MAC online portals so that providers can access real-time eligibility information, reduce the likelihood of billing errors, and tailor care plans to the specific benefits of each patient.

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