In an effort to decrease pharmacist time spent on the phone
obtaining eligibility information, Medicare created an electronic eligibility
check, also called an E1 transaction. This service, provided at a fee by Per-Se
Technologies (formerly NDCHealth), had some difficulties at launch but is now
fully functioning. Here are a few
tips to help you provide accurate information and, consequently, limit any
unnecessary expense by sending incomplete claims to the electronic eligibility
check.
Tip #1: The gold standard. The most important information for the E1 system is the beneficiary’s Medicare ID. The number should be entered into the Cardholder ID field exactly as it is shown on the patient’s blue and white Medicare card.
Tip #2. The next best thing. If you do not have the patient’s Medicare ID number, the patient’s complete Social Security number is the next best thing. It is important that you do not include any dashes when entering this information.
Tip #3. Other eligibility identifiers. If the patient’s Medicare ID number and Social Security number are not available, you can input other patient identifiers to match the eligibility system. These include ZIP code, gender, last name, first name, birthday. This is not a preferred method to access eligibility. However, the system will attempt to match based on this information.
Tip #4. Who to contact? If you are experiencing difficulties accessing the E1 system, contact your software vendor. If you are receiving incomplete or no information from the E1 system, Medicare has established a pharmacist-only help desk line. You can call 866-835-7595, 24 hours a day, 7 days a week to obtain eligibility information.
More complete information is available here.