Print the complete Portal User Manual 
Eligibility Check allows providers to verify certain information Medicare has on file for Medicare beneficiaries. This information helps providers bill Medicare correctly. Information is generally available 24 hours a day but may be temporarily unavailable due to scheduled or unscheduled maintenance.
Sources of Eligibility Data
The eligibility information available in the WPS Government Health Administrators Portal comes from the HIPAA Eligibility Transaction System (HETS) 270/271 eligibility transaction. The information available in the portal is the same information provided by the Interactive Voice Response (IVR). It is important to understand that while eligibility information is accurate at the time it is given, the information may change if Medicare (or any of the Federal agencies that supply data to HETS, such as the Social Security Administration) receives additional information. Although the data from HETS is updated in real time, the data comes from many different sources that may take up to two weeks to update. Medicare contractors process claims based on the information on Medicare’s files at the time the claim is processed.
If you have a question about a patient’s eligibility information, you or the patient should contact the entity responsible for providing the data to Medicare:
- Contact the Social Security Administration for questions about Medicare entitlement or benefit dates.
- Contact the Benefits Coordination and Recovery Center (BCRC) for Medicare Secondary Payer (MSP) questions. The BCRC can also assist with some issues involving Medigap or supplemental insurance (i.e., insurance that pays after Medicare).
- Contact the Medicare Advantage (MA) plan (i.e., Managed Care Organization or Medicare replacement plan) directly for all questions involving MA plans.
- Contact your state’s Medicaid agency for questions about the Qualified Medicare Beneficiary (QMB) program.
Accessing Eligibility Check
You can access Eligibility Check by clicking on the link under the My Transactions heading in the left navigation menu.
After clicking the link, select your service location (if it is not already prepopulated) and enter the following information about your patient:
- Medicare number (i.e., the Medicare Beneficiary Identifier (MBI))
- First name -OR- Date of birth
- Last name
- Suffix, if applicable (e.g., Jr., Sr., III, etc.)
- Starting and ending dates of service (DOS)
NOTE: The eligibility information provided corresponds to the starting and ending dates of service you enter on the search screen. You can search for eligibility information up to four years in the past or 4 months in the future by changing the dates in the Starting DOS and Ending DOS fields.
Click the Check Eligibility button to start the search. If any of the information you entered is incorrect, you will see an error message.
If the information you entered is valid, the portal will display the beneficiary’s basic details along with links to additional eligibility categories.
- The category box is blue if eligibility information is available.
- The category box is gray if no eligibility information is available in that category.
You can also refine your search or start a new one, jump to the Claim Inquiry page (which will be prepopulated with the beneficiary’s Medicare number), or print the beneficiary’s eligibility details from this screen.
Available Eligibility Information
Use the tabs located above the patient’s details to see additional eligibility information for your patient. The tabs highlighted in blue contain additional information for your patient. The order of the tabs will vary depending on the eligibility information available. The information available includes:
NOTE: Medicare Diabetes Prevention Program (MDPP) suppliers have limited access to eligibility information. The data available is limited to the information an MDPP supplier would need to bill for MDPP services: Part B eligibility date, managed care organization (MCO) data, Medicare secondary payer (MSP) data, and end-stage renal disease (ESRD) data.
Summary
The Summary tab provides the following entitlement and benefit information:
- Part A and Part B entitlement dates
- Part A and Part B entitlement reason codes (Hover your mouse over the code to display the definition of the reason code.)
- Previous Part A and Part B entitlement dates
- Part A and Part B ineligible dates (A beneficiary may have periods of ineligibility during their Medicare entitlement. The portal will show periods of ineligibility occurring within your search parameters.)
- Part A benefit data:
- Lifetime reserve days
- Lifetime reserve co-payment amount
- Lifetime psychiatric days
- Hospital days
- Hospital co-payment days and amount
- Skilled nursing facility (SNF) days
- Skilled nursing facility (SNF) co-payment days and amount
- Part B benefit data:
- Pulmonary rehabilitation sessions
- Blood deductible
- Smoking cessation sessions
- Cardiac rehabilitation sessions
- Intensive cardiac rehabilitation sessions
- Link to a list of procedure codes that require Prior Authorization
Return to Available Eligibility Information
Part A Deductible
The Part A Deductible tab provides the following information:
- Coverage time span (year)
- Part A deductible amount
- Hospital spell dates (earliest/latest billing date and days remaining) and deductible remaining
- Hospital co-payment amount and days remaining
- Hospital stay dates and billing NPI
- SNF spell dates (earliest/latest billing date and days remaining) and deductible remaining
- SNF co-payment amount and days remaining
- SNF stay dates and billing NPI
Return to Available Eligibility Information
Part B Deductible
The Part B Deductible tab provides the following information:
- Coverage time span (year)
- Part B deductible amount
- Part B deductible remaining
Return to Available Eligibility Information
Medicare Advantage (MA)
The MA tab provides information about insurance that pays INSTEAD of Medicare. This type of insurance is known by many names, including Medicare Part C, Medicare HMO, Medicare managed care organization, Medicare health plan, or Medicare replacement plan. When a beneficiary enrolls in a Medicare Advantage plan, they remain enrolled in Medicare, but they elect to have their Medicare-covered services processed and paid by another insurer. In exchange for allowing the other insurer to manage their care (which usually includes limiting the beneficiary to a network of providers), the beneficiary may receive additional benefits that aren’t covered under Original Medicare. In most cases, the provider submits a claim only to the MA plan. Though uncommon, some MA plan options allow beneficiaries to see out-of-network providers and have those services processed by Original Medicare instead of by the MA plan.
The MA tab provides the following information:
- MA plan enrollment and termination dates
- MA contract and plan
- MA name, address, telephone number, and website (if available)
- MA enrollment plan type
- Bill option code
- MA and plan benefit package (PBP) information are displayed on separate lines
Return to Available Eligibility Information
Preventive Services
The Preventive Services tab provides the following information about the preventive services Medicare covers subject to specific frequency limitations (e.g., repeat preventive services covered only after a set amount of time has passed):
- Procedure code (with professional/technical modifier, if applicable)
- Next eligible date
- Pneumococcal pneumonia vaccination history (procedure code, rendering provider’s NPI, and date of service)
- Influenza (procedure code, rendering provider’s NPI, and date of service)
- COVID-19 Immunization Data (procedure code, immunization date, and rendering provider’s NPI)
The portal displays current eligibility data only. You should not infer historic eligibility or prior services rendered based on the next eligible date. (For example, do not infer that the patient previously received a colonoscopy based on the date the patient is next eligible for a colonoscopy.)
If a procedure code has different next eligible dates for the professional and technical components, the portal will display different eligibility dates for each component.
The portal displays the procedure codes that may be used to bill for preventive services that have a specific frequency limitation, including:
- Alcohol misuse screening and counseling (G0442 and G0443)
- Annual Wellness Visit (AWV) (G0438 and G0439)
- Audiology Screening (92550, 92552, 92553, 92555, 92556, 92557, 92562, 92563, 92565, 92567,92568, 92570, 92571, 92572, 92575, 92576, 92577, 92579, 92582, 92583, 92584, 92587, 92588, 92601, 92602, 92603, 92604, 92620, 92621, 92625, 92626, 92627, 92640, 92651, 92652, and 92653)
- Bone mass measurement (76977, 77078, 77080, 77081, and G0130)
- Cardiovascular disease screening (80061, 82465, 83718, and 84478)
- Colorectal cancer screening (G0104, G0105, G0106, G0120, G0121, G0327, G0328, and 82270)
- Depression screening (G0444)
- Diabetes screening (82947, 82950, and 82951)
- Glaucoma screening (G0117 and G0118)
- Hepatitis B screening (G0499)
- Hepatitis C screening (G0472)
- Human Immunodeficiency Virus (HIV) screening (G0475)
- Intensive behavioral therapy (IBT) for cardiovascular disease (CVD) (G0446)
- Intensive behavioral therapy for obesity (G0447)
- Initial Preventive Physical Examination (IPPE) (G0402, G0403, G0404, and G0405)
- Prostate cancer screening (G0102 and G0103) (males only)
- Screening for cervical cancer with human papillomavirus (HPV) (G0476) (females only)
- Screening for sexually transmitted infections (STIs) and high intensity behavioral counseling (HIBC) to prevent STIs (G0445)
- Screening mammography (77067)
- Screening Pap tests (G0123, G0143, G0144, G0145, G0147, G0148, P3000, and Q0091)
- Screening pelvic exam (G0101)
- Ultrasound screening for abdominal aortic aneurysm (AAA) (76706)
For more information about preventive services, including those services that are not included on the Preventive Services tab, see the Medicare Preventive Services tool on the CMS website.
Return to Available Eligibility Information
Prescription Drug Plan (PDP)
The PDP tab provides information about any Medicare Part D prescription drug plans the beneficiary has enrolled in. While these plans are called Medicare Part D, they are stand-alone prescription drug plans offered by private insurers, not Original Medicare. Providers who have questions about a patient’s PDP should contact the PDP insurer directly. The PDP tab provides the following information:
- PDP enrollment and termination dates
- PDP contract and plan numbers
- Part D insurer’s contact information, including:
- Insurer’s name
- Insurer’s address
- Insurer’s telephone number
- Insurer’s website (if available)
- PDP plan name
Return to Available Eligibility Information
Therapy Caps
The Therapy Caps tab provides information about the annual per-beneficiary threshold limitations on physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. In previous years, Medicare set financial limitations on the therapy services beneficiaries could receive in a calendar year. The Bipartisan Budget Act (BBA) of 2018 repealed those caps and added a limitation to ensure beneficiaries receive appropriate therapy. Though it is more accurate to refer to the limitations as per-beneficiary thresholds or KX modifier thresholds, they are commonly called “therapy caps.”
There are two separate thresholds for therapy services: One for PT and SLP services combined and another for OT services. The Therapy Caps tab provides the following information:
- Type of therapy (Note: While the types of therapy are labeled either occupational therapy or physical therapy on this screen, remember physical therapy also includes speech-language pathology services)
- Deductible year
- Amount applied toward threshold (labeled “Part B Therapy Cap Used”)
Return to Available Eligibility Information
Medicare Diabetes Prevention Program (MDPP)
The MDPP tab provides information about Medicare Diabetes Prevention Program (MDPP) eligibility. The MDPP is a once in a lifetime benefit for eligible beneficiaries at risk of developing type 2 diabetes. Medicare Part B covers an initial 12-month period (six months of weekly sessions followed by six additional months of monthly sessions). Medicare can also cover a second 12-month period of maintenance sessions if the beneficiary meets certain criteria.
The MDPP tab provides the following information:
- MDPP effective and termination dates
- Inactive coverage
- Active coverage
- MDPP HCPCS codes billed
- Billing Provider NPI
- Date of Service for each HCPCS code
- MDPP Period 2 End Date
NOTE: The effective date for active coverage only displays the starting date of service you submitted on your eligibility request. It is NOT the actual start date for the beneficiary’s MDPP. If the beneficiary’s MDPP enrollment is not active, it will display the starting date of service submitted on your eligibility request on the Inactive Coverage line.
Return to Available Eligibility Information
Additional Coverage
The Additional Coverage tab provides information about Medicare’s coverage of acupuncture for chronic low back pain. Medicare Part B covers up to 12 acupuncture visits in 90 days to treat low back pain. Medicare can also cover 8 additional sessions if the initial sessions improve the beneficiary’s low back pain. No more than 20 acupuncture treatments are covered annually.
Also found on the Additional Coverage tab is Cognitive Assessment and Care Plan services data provided there is not a recorded date of death prior to or equal to the requested date(s) of service. If there are no services provided during the request date(s) of service but there is prior usage, the portal will include the most recent service occurrence.
The Additional Coverage tag provides the following information:
Acupuncture:
- Technical sessions remaining
- Next technical date
- Professional sessions remaining
- Next professional date
Cognitive Assessment and Care Plan:
- HCPCS 99483
- Date of service
- Rendering provider NPI
Return to Available Eligibility Information
Qualified Medicare Beneficiary (QMB)
The QMB tab provides information Qualified Medicare Beneficiary (QMB) eligibility. A QMB is eligible for both Medicare and Medicaid. Medicare providers and suppliers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays. Providers may be eligible to bill state Medicaid programs for those costs. People in the QMB program have no legal obligation to pay Medicare providers for Medicare Part A or Part B cost-sharing amounts even if the provider is not enrolled in the state’s Medicaid program. For more information, see the CMS website.
The QMB tab provides the following information:
NOTE: State Medicaid agencies determine QMB eligibility monthly, but they may not update the systems that supply eligibility data to Medicare by the first day of each month.
Return to Available Eligibility Information
Medicare Secondary Payer (MSP)
The MSP tab provides information about insurance that pays BEFORE Medicare pays. When a beneficiary has two or more insurers, there are rules that determine which insurer pays first. Some types of primary insurance, such as employer group health plans, pay before Medicare for all types of services. Other types of primary insurance, such as worker’s compensation or liability insurance, only pay before Medicare for services related to an accident or injury. In most cases, the provider submits a claim to the MSP insurer first and then submits a claim to Medicare. For more information, see the CMS website.
See our Medicare Secondary Payer (MSP) Fact Sheet for information on determining who is Primary to Medicare.
The MSP tab provides the following information:
- Enrollment and termination dates
- Insurer name and address
- Insurance type code and description
- Policy ID
- Group Number
- Last MSP Maintenance Date
- Patient Relationship Code
- MSP Source Code
- Diagnosis codes associated with the beneficiary’s accident or injury
- ORM Indicator
Return to Available Eligibility Information
End Stage Renal Disease (ESRD)
The ESRD tab provides eligibility information for beneficiaries eligible for Medicare due to their end stage renal disease. Medicare eligibility due to ESRD works differently than other types of Medicare eligibility. Medicare’s coverage depends on when the beneficiary begins or ends regular dialysis treatments or receives a kidney transplant. For more information about Medicare eligibility due to ESRD, see the CMS website.
The ESRD tab provides the following information:
- ESRD coverage period effective date and end date
- Dialysis start and end date (if applicable)
- Kidney transplant date (if applicable)
Return to Available Eligibility Information
Home Health
The Home Health tab provides information about home health periods of care. Home health agencies (HHAs) submit a consolidated bill to Medicare for the home health services a beneficiary receives during a home health episode of care. With limited exceptions, Medicare will only pay the HHA for the home health services and medical supplies a beneficiary receives during each 30-day period of care. For more information, see the CMS website.
The Home Health tab provides the following information:
- Home health period start and end dates
- Date of earliest and latest billing activity
- HHA provider NPI
- Contractor number and name
- Patient status code (indicating whether the beneficiary is actively receiving services)
- Notice of Admissions (NOA) Indicator
- 1 – NOA Received without condition code 47
- 2 – NOA received with condition code 47
Return to Available Eligibility Information
Hospice
The Hospice tab provides information about benefit periods once a beneficiary elects to receive hospice care. When a beneficiary elects to receive hospice care, they agree to receive palliative care instead of treatment to cure their terminal illness. Hospice care is available for two periods of 90 days and an unlimited number of subsequent 60-day periods. For more information, see the CMS website.
The Hospice tab provides the following information:
Hospice Election Period Information (The Hospice Election Revocation Indicator will now be sourced from the specific Hospice Election record instead of the Hospice Period record):
- Hospice provider NPI
- Start date
- Receipt date
- Revocation date
- Revocation code
Hospice Benefit Period Information:
- Benefit period provider NPI
- Start and end date
- Dates of earliest and latest billing activity
- Number of hospice days used
Return to Available Eligibility Information
Part B Immunosuppressant Drug (PBID)
The PBID tab provides Enrollment information for Medicare beneficiaries following a kidney transplant. This benefit provides coverage for immunosuppressant drugs beyond the 36 months following a kidney transplant. This will only cover immunosuppressive drugs and no other services or items. The HETS response will return up to ten (10) Part B-ID enrollment periods within the requested date(s) of service. The HETS response for Part B-ID will never include Medicare Advantage (MA) or Medicare Secondary Payer (MSP) data.
The PBID tab provides the following information:
- Enrollment Reason Code
- Coverage Time Span
- Deductible Base
- Deductible Remaining
- Coinsurance
Return to Available Eligibility Information
Supplemental Insurance
The Supplemental Insurance button provides information about insurance that may pay for services after Medicare processes the claim. Unlike the other eligibility information, the supplemental insurance information is available by clicking a button located above the row of eligibility information tabs.
The supplemental insurance information available is for informational purposes only. It may not be a comprehensive list of any or all the supplemental insurance a beneficiary may have. Medicare’s information is limited to Medicare Crossover trading partners that sign trading partner agreements with Medicare. A trading partner agreement allows Medicare to send claim information to the supplemental insurer after Medicare processes the claim. Beneficiaries may have other insurance that would require the provider to file a claim directly with the insurer. Providers should obtain supplemental insurance information from the beneficiary.
The Supplemental Insurance tab provides the following information:
- Supplemental insurer’s name and address
- Supplemental insurance effective and termination date
- Coordination of benefits agreement (COBA) number
Return to Available Eligibility Information
Web Content Viewer
(866) 518-3285