Common questions about RPM and CCM eligibility checks and claims

Remote patient monitoring (RPM) and chronic care management (CCM) don't bill like office visits. A provider bills these services at the end of every month, not once per encounter.

Each monthly claim depends on the patient's coverage that month. For many RPM and CCM patients, that coverage is Medicare. In 2026, 55% of eligible Medicare patients have a Medicare Advantage plan instead of Original Medicare, according to KFF.

Original Medicare and Medicare Advantage claims go to different payers. If you don't know which plan the patient has, a month of claims can go to the wrong payer.

This guide answers questions we commonly hear from RPM and CCM teams that use Stedi. It also applies to companies that run these programs for provider groups.

How do I find out if a patient has Original Medicare or Medicare Advantage?

The answer decides where each month's RPM or CCM claim goes. Many patients don't know which plan they have. Some show their red, white, and blue Medicare card even though they're on a Medicare Advantage plan.

If the patient has a card from a commercial payer, send an eligibility check to that payer first. Use the plan's member ID, not the patient's Medicare Beneficiary Identifier (MBI).

If you only have a Medicare card, send an eligibility check to the Centers for Medicare & Medicaid Services (CMS). Use payer ID CMS. If you don't have the MBI, run an MBI lookup. Use payer ID MBILU, or MBILUNOSSN if you don't have the patient's Social Security Number.

For how to read each response, see Medicare Advantage eligibility made easy.

Run CMS checks and MBI lookups only for patients you plan to bill Medicare for. Don't run them across a patient list to find Medicare Advantage patients. These rules come from the Rules of Behavior for HETS, CMS's eligibility system.

For a Medicare Advantage patient, the CMS response names the plan as the primary payer. It also includes an MA Bill Option Code. With codes A and 1, the Medicare Administrative Contractor (MAC) processes the patient's claims instead of the plan. For the full code list, see How to read a 271 eligibility response in plain English.

Do Medicare eligibility checks require transaction enrollment?

For Original Medicare, yes. Each billing provider's National Provider Identifier (NPI) needs its own transaction enrollment with CMS. The NPI must also be active in PECOS, CMS's provider enrollment system.

CMS enrollment includes an attestation step. The provider must complete it themselves, one NPI at a time. It takes 5-15 minutes per NPI. If you run RPM or CCM programs for many provider groups, plan for each provider to attest.

If a CMS check fails because the NPI isn't enrolled, Stedi submits the enrollment request for you. The provider still needs to complete attestation.

MBI lookups need separate enrollments for MBILU and MBILUNOSSN. Stedi submits MBILU enrollments for you after a failed lookup. Submit MBILUNOSSN enrollments yourself.

Most Medicare Advantage and commercial payers don't require transaction enrollment for eligibility checks. To confirm, check the payer in the Stedi Payer Network.

Which STCs should I use for RPM and CCM eligibility checks?

Most medical payers don't support eligibility inquiries for procedure codes, like 99454 for RPM. Send a Service Type Code (STC) instead.

Each payer maps procedure codes to STCs in its own way, so you'll need to test them.

Step 1. Start with STC 30 (Health Benefit Plan Coverage)

All medical payers support STC 30, which makes it a baseline.

Step 2. Test more specific STCs

Try the STCs in this table for the codes you bill. Send one STC per request.

The STCs are 73 (Diagnostic Medical), 98 (Professional (Physician) Visit – Office), and 96 (Professional (Physician)). The others are DM (Durable Medical Equipment), CQ (Case Management), and 1 (Medical Care).

Step 3. Compare to the baseline

If a response returns benefits that STC 30 didn't, the payer supports that STC. If the responses are identical, the payer may not support the STC, or the plan may not cover the service. Repeat the tests for each payer.

For more on STC tests, see How to pick the right STC. To find the STCs for other procedure codes, use our free CPT/HCPCS to STC lookup tool.

Will the patient owe a cost share?

Usually, yes.

Original Medicare. RPM and CCM are Part B services, so the Part B deductible and 20% coinsurance apply. The deductible doesn't apply to services billed by Federally Qualified Health Centers (FQHCs). An eligibility check shows how much of the deductible the patient has left. For where to find it, see our patient responsibility docs. CMS requires the provider to tell the patient about this cost share as part of CCM consent.

Many Original Medicare patients have other coverage, such as Medigap, an employer plan, or Medicaid. These plans could also contribute financially to the cost of care. Coordination of benefits (COB) checks find a patient's other coverage and show which plan pays first. They don't support Original Medicare, so check the CMS response for other-payer information instead. It may not list every plan. If the patient may have Medicaid, send a check to the state Medicaid payer. You can also run an insurance discovery check.

Medicare Advantage. Medicare Advantage plans set their own cost share, so check the Medicare Advantage payer's response, not the CMS response. Many Medicare Advantage plans support COB checks. A COB check finds additional coverage and shows which plan pays first.

What if the patient is a Qualified Medicare Beneficiary (QMB)?

More than 1 in 8 Medicare patients are QMBs. QMB is a Medicaid program that pays Medicare premiums and cost shares for low-income patients.

Under federal law, providers can't bill QMBs for Part A or Part B deductibles, coinsurance, or copays. This applies to Original Medicare and Medicare Advantage patients, even if Medicaid doesn't pay the full cost share.

For Original Medicare patients, the CMS eligibility response can show a QMB period. Look for an insuranceType of QUALIFIED_MEDICARE_BENEFICIARY in the plans shape, or an insuranceTypeCode of QM in the benefitsInformation shape. Make sure the period covers the month you bill. If you're unsure, confirm QMB status with the state Medicaid program. For Medicare Advantage patients, ask the plan how it reports QMB status.

For more about QMB and other Medicare details, see How to map a Medicare 271 eligibility response to a CWF.

How often should I check eligibility for RPM and CCM patients?

Check before you bill each month. A patient's plan can change from one month to the next. Patients with Medicaid or Extra Help can leave a Medicare Advantage plan for Original Medicare once a month.

Original Medicare patients

Check Original Medicare patients only when you're about to bill them. If CMS sees too many checks without claims, it may suspend a provider's access.

Medicare Advantage, Medicaid, and commercial patients

Run batch eligibility checks at the start of each month. You can include up to 10,000 checks in a single request. For tips on when to schedule them, see How to optimize monthly eligibility refresh checks.

January 1

Plan changes from Medicare's annual enrollment period take effect on January 1. Medicare Advantage patients can switch plans again through March 31. Those changes can take effect as late as April 1.

Run a full check for every patient before you bill January services. For more tips, see Tips for annual eligibility refreshes.

Can an eligibility check tell me if another provider billed RPM or CCM this month?

No. Eligibility responses don't show other providers' claims.

Medicare pays only one provider per patient for CCM each calendar month. RPM has the same limit for each 30-day period. If another provider billed first, the payer will deny your claim.

When a patient starts RPM or CCM, ask if another provider manages their care or gave them a monitoring device.

Which codes go on RPM and CCM claims?

Most RPM and CCM codes are Current Procedural Terminology (CPT) codes. G0506 and the Advanced Primary Care Management (APCM) codes are Healthcare Common Procedure Coding System (HCPCS) Level II codes. As of January 1, 2026, CPT includes two new RPM codes for shorter monitoring and management periods: 99445 and 99470.

RPM and CCM billing codes

Bill either 99454 or 99445 for a 30-day period, not both. For treatment management, bill 99470 for 10-19 minutes in a month. Once time reaches 20 minutes, bill 99457 instead.

Some primary care practices bill APCM instead of CCM. APCM uses three monthly codes, G0556-G0558, that aren't time based. A provider can't bill APCM and CCM for the same patient in the same month. They can bill APCM alongside RPM.

For current rules and payment rates, see CMS's Physician Fee Schedule.

How do I submit RPM and CCM claims?

Most practices submit RPM and CCM on professional claims. FQHCs and Rural Health Clinics (RHCs) use institutional claims instead. You can submit both types with Stedi's APIs, SFTP, or the Stedi portal.

Where you send the claim depends on the plan from your eligibility check:

• Original Medicare: Send the claim to the MAC for the area where the provider furnishes the service, not to CMS. To find the right MAC, see How to find the right payer for Medicare claims.
• Medicare Advantage: Send the claim to the Medicare Advantage payer. The MA Bill Option Code can change this. With A or 1, send all claims to the MAC. With B or 2, the plan processes only Part B claims from its service area.

Original Medicare claims for patients with Medigap often cross over to the Medigap payer automatically.

To receive Electronic Remittance Advice (ERAs), each provider needs ERA transaction enrollment with each payer. This includes MACs and Medicare Advantage payers. Payers require it even when they don't require transaction enrollment for eligibility checks. You can submit ERA enrollments through Stedi.

Stedi runs every claim through claim edits that mimic the checks payers use.

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