Medicare Advantage eligibility made easy

Big takeaway: For Medicare Advantage plans, send eligibility checks to the commercial payer, not CMS.

Verification and billing for Medicare Advantage plans can be confusing. It’s easy to send a request to the wrong payer or miss an important detail.

This guide aims to make it simple. It covers how to spot Medicare Advantage plans, where to send eligibility checks, and how to submit claims.

What is Medicare Advantage?

A Medicare Advantage plan – also called Medicare Part C – is a health plan from a private payer that’s approved by Medicare. It serves as an alternative to Original Medicare. 

Medicare Advantage plans cover benefits included in Medicare Part A (hospital benefits) and Part B (medical benefits). Along with those benefits, Medicare Advantage plans often provide extra coverage like prescription drugs, vision, dental, and hearing. 

Eligibility checks for Medicare Advantage plans

When running eligibility checks for Medicare Advantage plans:

• Send the check to the plan’s commercial payer.
  Don’t send the check to the National Centers for Medicare & Medicaid Services (CMS) – the government payer for Medicare.
  
  

• Check the payer ID.
  Some payers have separate payer IDs for Medicare Advantage plans and other lines of business, like employer-sponsored plans. For example, CareFirst Medicare Advantage vs CareFirst Blue Cross Blue Shield Maryland.
  
  Use the payer ID for the Medicare Advantage payer. You can get the ID using the Stedi Payer Network or Payers API.
  
  

• Transaction enrollment isn’t typically required.
  Most Medicare Advantage payers don’t require transaction enrollment for eligibility checks. You can check for transaction enrollment requirements using the Stedi Payer Network or Payers API.
  
  

• Use the commercial plan’s member ID – if required.
  Many Medicare Advantage plans allow eligibility checks with just the patient’s first name, last name, and date of birth.
  
  If a member ID is required, use the commercial plan’s member ID, not the patient’s Medicare Beneficiary Identifier (MBI) used for Medicare.

How to spot a Medicare Advantage plan in an eligibility response

Providers often want to know if a plan is a Medicare Advantage plan. These plans often have different prior authorization requirements and reimbursement rates than traditional Medicare.

To spot a Medicare Advantage plan in a commercial payer’s eligibility response, look for either of the following indicators in the JSON Eligibility API's response:

• benefitsInformation.insuranceTypeCode = MA (Medicare Part A) or MB (Medicare Part B)
  
  

• planInformation.hicNumber or benefitsInformation.benefitsAdditionalInformation.hicNumber, which contains the patient’s MBI.

{
  "benefitsInformation": [
    {
      "code": "1",                 // Active Coverage
      "serviceTypeCodes": ["30"],  // Health Benefit Plan Coverage
      "insuranceTypeCode": "MA",   // Medicare Part A
      ...
      "benefitsAdditionalInformation": {
        "hicNumber": "1AA2CC3DD45" // Patient's MBI
      },
      ...
    },
    ...
  ],
  ...
}

What is a HIC number?
The hicNumber property name refers to a Health Insurance Claim (HIC) Number, the old member ID system for Medicare. HIC numbers were usually a Social Security Number plus a letter, such as 123-45-6789A.

CMS now uses MBIs for member IDs – and that’s usually what fills these properties when present. MBIs are 11 characters: numbers and capital letters, no spaces. For MBI formatting rules, see CMS’s Understanding the MBI doc.

Medicare Advantage plans in CMS eligibility responses

Sometimes, a patient may be confused about whether they’re covered by Original Medicare or Medicare Advantage.

You may run an eligibility check with CMS (the Medicare government payer) or an MBI lookup (which returns a CMS eligibility response on a match), only to discover through the response that the patient actually has Medicare Advantage coverage.

If the patient has Medicare Advantage, the eligibility response from CMS will include a benefitsInformation object with the following:

• code = U (Contact Following Entity for Eligibility or Benefit Information)

• serviceTypeCodes = 30 (Health Benefit Plan Coverage)
  OR
  serviceTypeCodes = 30 AND CQ (Case Management

• insuranceTypeCode = HM (HMO), HN (HMO - Medicare Risk), IN (Indemnity), PR (PPO), or PS (POS)

• benefitsInformation.benefitsRelatedEntities.entityIdentifier = Primary Payer

The name of the Medicare Advantage payer is usually in the object’s benefitsRelatedEntities.entityName property. For example:

{
  "benefitsInformation": [
    {
      "code": "U",	// Contact Following Entity for Eligibility or Benefit Information
      "serviceTypeCodes": ["30"],	 // Health Benefit Plan Coverage
      "insuranceTypeCode": "HM",	 // HMO
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Primary Payer",
          "entityName": "BLUE CROSS MEDICARE ADVANTAGE",
          ...
        }
      ],
      ...
    },
    ...
  ],
  ...
}

Note: Don’t use CMS eligibility checks to verify Medicare Advantage coverage. CMS prohibits this.

Coordination of benefits (COB) checks for Medicare Advantage

Medicare Advantage patients often have supplemental insurance or employer-sponsored coverage that could be primary or secondary.

A COB check can help you determine the correct billing order. Most Medicare Advantage plans are supported.

Medicare vs. Medigap

Although Medicare Advantage patients often have supplemental insurance, they won’t have Medigap.

Medigap – also called Medicare Supplement Insurance – is supplemental insurance that helps pay out-of-pocket costs (like deductibles and coinsurance) for people with Original Medicare. 

• Medigap is completely separate from Medicare Advantage.
  
  

• You can’t have Medigap and Medicare Advantage at the same time.
  Payers can’t sell someone Medigap if they’re on a Medicare Advantage plan.
  
  

• Medigap only works with Original Medicare, not Medicare Advantage. 

Medicare Advantage claims

Submit claims for Medicare Advantage plans to the commercial payer – just as you would for any commercial health plan. Don’t send Medicare Advantage claims to CMS.

Get started

You can run eligibility checks, MBI lookups, and COB checks – and submit claims – using any paid Stedi developer plan.

If you don't have a paid developer plan, request a free trial. We get most teams up and running in under a day.