How to do Eligibility enquiry - Medicare process

Eligibility Inquiry

This electronic transaction can be used to inquire about the eligibility, coverage, or benefits associated with a health plan, employer, plan sponsor, subscriber, or a dependent under the subscriber's policy. It also can be used to communicate information about, or changes to, eligibility, coverage, or benefits from information sources (such as insurers, sponsors, payers) to information receivers (such as physicians, hospitals, third party administrators, government agencies).

The Centers for Medicare & Medicaid Services (CMS) is making changes to its Information Technology infrastructure to address standards for beneficiary eligibility inquiries to the Medicare Fee-For-Service (FFS) program. The changes will create the necessary national database and infrastructure to provide HIPAA compliant 270/271 health care eligibility inquiries and responses on a real-time basis.

CMS is using a phased approach for providing this eligibility transaction on a real-time basis:

Extranet: Since May of 2005, entities that wish to submit 270s to Medicare on a real-time basis (hereinafter, "Submitter" or "Submitters") have been permitted to submit 270s via the CMS AT&T communication Extranet (the Medicare Data Communication Network, or MDCN). This Extranet is a secure closed private network currently used to transmit data between Medicare FFS contractors and CMS, as well for transmission of electronic transactions in some cases from certain providers and clearinghouses to FFS contractors.

Internet: Internet access to conduct the eligibility transaction on a real-time basis is being developed. Instructions on conducting the eligibility transaction via this method will be provided prior to the time Internet access becomes available.

Regardless of the access method employed, all eligibility inquiries will be processed at the CMS data center. The CMS Data Center will use a single consolidated national eligibility database to respond to the eligibility inquiries.

Access Process : Complete the form linked to below. Once complete, a copy of the completed electronic form will be electronically submitted to the CMS 270/271 Medicare Eligibility Integration Contractor (MEIC) for security authentication. The access process will then continue, and the Submitter will be directed to complete an MDCN connectivity form in order to be connected to the 270/271 eligibility database. Once the MDCN connectivity form is completed, it will automatically be directed to the CMS/MDCN staff and to the MEIC for completion of the connectivity process and authentication. Once these processes have been completed, the MEIC will provide the Submitter with a submitter ID, which must be used on all 270/271 transactions. Please note that in order to access the MDCN, Submitter must obtain the necessary telecommunication software from an AT&T reseller.