Jurisdiction 1 Part B

Entering Beneficiary Information: OPS Eligibility Inquiry vs. Claim Submission

Last updated on 02/26/2013

Palmetto GBA acknowledges that providers are asked to enter beneficiary information into Online Provider Services (OPS) when obtaining eligibility in a different manner than when submitting a claim. This article explains how to enter beneficiary information for each task: obtaining beneficiary eligibility from OPS and submitting a claim.

OPS Eligibility Inquiry
The user should enter the beneficiary’s information into the fields listed on the Eligibility Inquiry tab. To protect the privacy of beneficiary data, all fields entered, including optional fields, must match the beneficiary’s data as it is maintained by CMS’ HIPAA Eligibility Transaction System (HETS); otherwise, eligibility data will not be returned.

Note: Special characters are not accepted in HETS.

The following fields are required:

• Subscriber’s Last Name - The suffix (e.g., Jr, Sr, etc.) should be entered if the beneficiary has a suffix printed on their Medicare health insurance card. The suffix may be necessary to receive a valid eligibility response

• Subscriber’s First Name

• Subscriber Birth Date

• Subscriber Primary ID (HICN)

The subscriber is the patient, and is also referred to as a beneficiary by Medicare.

To successfully submit an eligibility inquiry, you are required to enter either the Subscriber’s Name or Subscriber’s Birth Date in addition to the Subscriber’s Last Name and Subscriber Primary ID.

The Health Insurance Claim Number (HICN) is the Medicare beneficiary identifier assigned by Medicare. When looking at the Medicare Health Insurance card, the HICN is the Medicare Claim Number displayed on the card.

You may enter data into optional fields, but these fields are not required to receive a valid Medicare beneficiary eligibility benefit response. If data entered into an optional field does not match the beneficiary's data maintained in CMS’ HETS system, eligibility data will not be returned on the eligibility response tabs.

The optional fields are as follows:

• Subscriber Name Suffix – In the event that you cannot locate the beneficiary when entering the suffix in the last name field, try entering the suffix in this field

• Subscriber Gender

• Date From

• Date To

Note: To retrieve all information available, you must enter a valid date range. The HETS 270/271 system that we are required to access for eligibility allows date requests up to 27 months in the past. This matches the timely claim filing limit.

Once you have successfully retrieved the beneficiary’s information, all of the other sub-tabs will display information related to that beneficiary.

For more information on OPS, please refer to the OPS FAQs located under the Online Provider Services section of your contract's home page.

Claim Submission
Providers should follow the tips below when submitting claims to avoid claim rejection.

• The beneficiary’s name and Medicare HICN must be submitted exactly as indicated on the Medicare card (e.g., submitting Bill instead of William as indicated on the card would result in a rejection)

• Hyphens and apostrophes count as a character and must be entered

• The first six digits of the last name must be an exact match, including spaces

• Make sure to include any spaces in the name (e.g., O Brian). Look carefully as spaces can be difficult to see on the Medicare card

• If the Medicare card shows a suffix (e.g., Jr., Sr., II, III, etc.), report the name exactly as shown

• For electronic claims, ensure the Electronic Data Interchange (EDI) loop for the suffix field is populated and the suffix is not added to the beneficiary’s last name

• Do not place hyphens or blanks in the HICN field

Providers will receive the same name and Medicare HICN they submitted on their claim returned on their Remittance Advice, even if the information submitted is incorrect. Instead of calling the Provider Contact Center (PCC), who will not be able to supply you with the correct information, you must obtain the correct name and Medicare HICN from the patient, their Medicare card or authorized representative. Then, re-file the claim with the correct information.

last updated on 02/26/2013

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