Claims and eligibility checks for CMS ACCESS

Medicare's ACCESS Model lets Medicare beneficiaries get care for chronic conditions, like high blood pressure or depression, through digital apps and devices.

For example, a patient struggling with obesity can sign up for Noom – a weight-loss coaching app – and get it covered by Medicare.

ACCESS launches on July 5, 2026, and is scheduled to run for 10 years. Many providers and billers have questions about how eligibility checks and claims work with ACCESS, like:

• Can a standard eligibility check confirm ACCESS eligibility?
• Which procedure codes do you use to bill for ACCESS?
• Where do you send ACCESS claims?

This guide answers those questions. It also shows you how to run Medicare eligibility checks and submit ACCESS claims with Stedi.

What is the ACCESS Model?

ACCESS stands for Advancing Chronic Care with Effective, Scalable Solutions. It's an alternative payment model for Medicare that lets patients with chronic conditions get care through apps, devices, and telehealth.

The program uses four clinical tracks:

Instead of paying a provider per patient visit, Medicare sends a participating digital health company – called an ACCESS Participant – a recurring monthly payment for managing the patient's condition.

Participants include companies like Berry Street, WHOOP, Headway, and Pair Team. You can view the full list on the Centers for Medicare & Medicaid Services (CMS) website.

ACCESS is billed under Medicare Part B. Patients covered under Medicare Advantage (Part C) aren't eligible for ACCESS.

How ACCESS works

CMS pays for ACCESS care through two payment types:

• Outcome-Aligned Payments (OAPs) for ACCESS Participants
• Co-Management Payments (CMPs) for the patient's regular clinicians

Outcome-Aligned Payments (OAPs)

Eligible Medicare beneficiaries can sign up as patients with ACCESS Participants.

CMS pays ACCESS Participants through Outcome-Aligned Payments (OAPs). The Participant bills Medicare one professional claim per patient per month. Each claim – called an OAP claim – contains a single service line with a procedure code related to its track.

CMS doesn't pay OAP claims directly: the claims' Electronic Remittance Advices (ERAs) will show a payment of $0. Instead, CMS issues the OAP as a separate payment.

The base OAP is 80% of the claim's allowed amount, which varies by track.

The remaining 20% is tied to outcomes. CMS looks at the share of the Participant's patients who hit their health outcome targets, like lowering blood pressure by 10 mmHg. If overall performance is strong, the Participant earns full payment, even if some patients fall short. Otherwise, the payment stays partial.

For more details, see CMS's OAP Billing Guidelines.

Co-Management Payments (CMPs)

The patient's primary care physician (PCP) or referring clinician can submit a separate claim for helping with the patient's ACCESS care. For example: reviewing the patient's progress or documenting a follow-up action.

Payments for these services are called Co-Management Payments (CMPs).

CMPs are capped at three payments per patient, per track, every 12 months. CMPs aren't subject to cost-sharing, like co-pays or deductibles.

To learn more, see CMS's CMP Billing Guidance.

Which patients are eligible for ACCESS?

To qualify for ACCESS, a patient must:

• Be enrolled in Medicare Part A and Part B.

• Have Medicare as their primary payer.

  Other coverage, like a Medigap or retiree plan, doesn't disqualify a patient. If another plan pays before Medicare, such as an employer plan through active employment, the patient isn't eligible.

• Have a qualifying diagnosis in one of the four ACCESS clinical tracks.

• Not be receiving hospice care.

• Not have end-stage renal disease (ESRD).

Patients must also complete an alignment process that matches them to a specific ACCESS Participant.

For the full criteria, see CMS's ACCESS eligibility requirements.

Can an eligibility check tell me whether a patient is eligible for the ACCESS Model?

No. CMS doesn't return ACCESS information in its eligibility responses. ACCESS eligibility depends on two things a standard eligibility check doesn't cover: a qualifying diagnosis and CMS's alignment process.

To confirm a patient's full ACCESS eligibility, use CMS's ACCESS Model APIs.

An eligibility check can screen for several ACCESS criteria, including Medicare coverage, hospice care, ESRD, and primary payer status. The following sections show how.

You can submit CMS eligibility checks (Payer ID: CMS) through Stedi using:

• JSON API
• X12 API
• SOAP endpoint
• Stedi portal UI
• Batch eligibility checks

For example, an eligibility check to CMS using Stedi's JSON Real-Time Eligibility API:

curl --request POST \
  --url "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3" \
  --header "Authorization: <api_key>" \
  --header "Content-Type: application/json" \
  --data '{
    "controlNumber": "123456789",
    "tradingPartnerServiceId": "CMS",
    "provider": {
      "organizationName": "Acme Health",
      "npi": "1999999984"
    },
    "subscriber": {
      "memberId": "1EG4TE5MK73",
      "firstName": "Jane",
      "lastName": "Doe",
      "dateOfBirth": "19500101"
    },
    "encounter": {
      "serviceTypeCodes": ["30"]  // Health Benefit Plan Coverage
    }
  }'

Check for Medicare coverage

ACCESS care is billed under Medicare Part B. To qualify for ACCESS, patients must be enrolled in both Medicare Part A and Part B.

To confirm coverage, look for active-coverage benefits – benefitsInformation objects with a code of 1 and an insuranceTypeCode of MA (Part A) or MB (Part B) – in the response. To meet the ACCESS criterion, the patient needs active coverage for both parts:

{
  "benefitsInformation": [
    {
      "code": "1", // Active Coverage
      "name": "Active Coverage",
      "insuranceTypeCode": "MA", // Medicare Part A
      "serviceTypeCodes": ["30"]
    },
    {
      "code": "1", // Active Coverage
      "name": "Active Coverage",
      "insuranceTypeCode": "MB", // Medicare Part B
      "serviceTypeCodes": ["30"]
    }
  ]
}

Check for hospice care

Patients receiving hospice care aren't eligible for ACCESS. If a patient has formally chosen (elected) the Medicare hospice benefit, the election periods appear in the CMS eligibility response. You can use these periods to check the related ACCESS criterion.

Hospice election periods appear as benefitsInformation objects with a code of X and a serviceTypeCodes of 45:

{
  "benefitsInformation": [
    {
      "code": "X", // Health Care Facility
      "name": "Health Care Facility",
      "serviceTypeCodes": ["45"], // Hospice
      "benefitsDateInformation": {
        "benefit": "20260110-20260408" // Election period start and end dates
      }
    }
  ]
}

Check for end-stage renal disease (ESRD)

Patients with end-stage renal disease (ESRD) aren't eligible for ACCESS. If CMS has ESRD coverage on file for a patient, it appears in the CMS eligibility response.

If the response doesn't include ESRD information, the patient may still have ESRD – a recent diagnosis may not be in CMS's records yet.

ESRD information appears as benefitsInformation objects with a code of D and a serviceTypeCodes of RN:

{
  "benefitsInformation": [
    {
      "code": "D", // Benefit Description
      "name": "Benefit Description",
      "serviceTypeCodes": ["RN"], // Renal
      "benefitsDateInformation": {
        "plan": "20250601", // ESRD coverage period
        "discharge": "20250315" // Dialysis date
      }
    }
  ]
}

Check for other payers

Patients are only eligible for ACCESS if Medicare is their primary payer. If CMS has another primary payer on file, the CMS eligibility response includes it.

To check for another primary payer, look for a benefitsInformation object with a code of R and an insuranceTypeCode, such as 12 (Medicare Secondary Working Aged Beneficiary), that indicates Medicare isn't the primary payer:

{
  "benefitsInformation": [
    {
      "code": "R", // Other or Additional Payor
      "name": "Other or Additional Payor",
      "insuranceTypeCode": "12", // Medicare Secondary Working Aged Beneficiary
      "benefitsDateInformation": {
        "coordinationOfBenefits": "20250101" // Start of the MSP period
      },
      "benefitsRelatedEntities": [
        {
          "entityName": "Acme Insurance Co" // The primary payer
        }
      ]
    }
  ]
}

The response only shows other coverage CMS knows about. If no other payer appears, Medicare may still be secondary. For example, CMS may not know about the patient's employer coverage. If you suspect the patient has other coverage, you can run an insurance discovery check with the patient's demographic information to find it.

Can I run a Medicare eligibility check for an ACCESS patient if I don't have their MBI?

No. A Medicare Beneficiary Identifier (MBI) is required for eligibility checks with CMS.

If you think a patient has Medicare Part B coverage but don't have their MBI, run an MBI lookup instead. MBI lookups only need demographic information, like the patient's name, date of birth, and optionally SSN.

Results aren't guaranteed, but a successful lookup returns the same information as an eligibility response, including the patient's MBI.

You can use the MBI and other information in the response to file an OAP or CMP claim for ACCESS services.

Do providers need to enroll to submit OAP or CMP claims for ACCESS?

Yes. To submit an OAP or CMP claim, providers must already be enrolled in Medicare Part B. Only CMS-approved ACCESS Participants can submit OAP claims.

Transaction enrollment

Medicare also requires providers to complete transaction enrollment to exchange specific transactions:

• Eligibility checks: You submit Medicare eligibility checks to CMS. You must complete transaction enrollment with CMS before running these checks.

• Claim submissions: You submit Medicare Part B claims to the Medicare Administrative Contractor (MAC) for the patient's jurisdiction. Most MACs require transaction enrollment for claim submissions.

• ERAs: The MAC you submit a claim to returns ERAs to the healthcare clearinghouse the MAC has on file for the provider.

  You change this clearinghouse through ERA transaction enrollment. You must complete ERA transaction enrollment to receive ERAs from a MAC through a clearinghouse like Stedi.

Stedi offers fully managed, API-based transaction enrollment. You can track and complete enrollments using our API or the Stedi portal.

Many Stedi payers support one-click enrollment. For these payers, you only need to submit an enrollment request. For other payers, Stedi handles transaction enrollment paperwork for you when possible.

Can I submit OAP and CMP ACCESS claims through Stedi?

Yes. Submit OAP and CMP claims as standard professional claims to the MAC that processes Part B claims for the patient's region. You can submit the claims through Stedi using:

• JSON API
• X12 API
• SFTP
• Stedi portal UI

For example, using the JSON Professional Claims Submission API:

{
  "claimInformation": {
    ...
    "serviceLines": [
      {
        "serviceDate": "20260805", // First day of ACCESS services for the month
        "professionalService": {
          "procedureCode": "G0669", // OAP G-code for eCKM initial period
          "serviceUnitCount": "1", // One unit of service per OAP claim
          ...
        }
      }
    ]
  }
}

CMS requires the claim's date of service to be the first day you provided ACCESS services to the patient that month. Claims submitted more than 90 days after the date of service aren't payable.

Important: On an OAP claim, the rendering provider (the clinician who delivered the care) must be on the Participant's Clinician Roster, the list of clinicians each Participant registers with CMS. The billing provider (the provider that gets paid) must use the Participant's Type 2 NPI.

What procedure codes do I use to bill for ACCESS?

To bill for ACCESS services, you use a track-specific G-code – a Healthcare Common Procedure Coding System (HCPCS) code that CMS maintains for its programs.

ACCESS Participants bill OAP G-codes; PCPs and referring clinicians bill CMP G-codes.

OAP G-codes

An OAP claim contains one service line: a single OAP G-code billed with one unit of service.

There are separate OAP G-codes for the initial 12-month period and additional 12-month follow-on periods.

Initial period OAP G-codes

Follow-on period OAP G-codes

The MSK track doesn't have a follow-on period.

CMP G-codes

PCPs and referring clinicians can bill the following G-codes for CMP claims:

PCPs and referring clinicians may also add the AC procedure modifier to the first CMP claim per patient per track. The modifier adds a one-time $10 onboarding payment.

Unlike OAP claims, CMP claims aren't limited to a single service line. A CMP claim can also include service lines for non-ACCESS services, like an office visit.

How do I find the MAC for an ACCESS patient?

MACs are payers that process Medicare claims in a specific region. For example, Noridian is the MAC for Medicare Part A and Part B claims in California and Arizona.

For current lists and maps of MACs and their jurisdictions, see Who are the MACs on the CMS site. Stedi connects to all MACs.

The Stedi Payer Network and Payers API also list records for "Medicare Part B" payers by state.

For example, if you search for "Medicare Arizona Part B," the payer ID in the resulting record routes claims to Noridian, the MAC for Medicare Part B claims in Arizona. The search request using the Payers API:

curl --request GET \
  --url "https://payers.us.stedi.com/2024-04-01/payers/search?query=Medicare+Arizona+Part+B" \
  --header "Authorization: <api_key>"

Response:

{
  "items": [
    {
      "payer": {
        "stediId": "NXLKN",
        "displayName": "Medicare Arizona Part B",
        "primaryPayerId": "03102", // payer ID for routing claims
        "names": [
          "Arizona Medicare",
          "Noridian (NHS) - Arizona" // Noridian is the Part B MAC for Arizona
        ],
        "operatingStates": ["AZ"],
        "programs": ["MEDICARE"],
        "transactionSupport": {
          "professionalClaimSubmission": "ENROLLMENT_REQUIRED"
        }
      }
    }
  ]
}

Use the primaryPayerId as the payer ID when you submit the claim.

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Sandbox accounts give you access to mock eligibility checks – including CMS checks – that you can use for testing or integration.

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