Beneficiary Lookup

The Beneficiary Lookup page allows you to determine if the insured party is a Medicare beneficiary and to query about their Medicare Secondary Payer coverage information. (Note: If a beneficiary is not found with the entered values, an error message will appear.)

Carefully enter the required information about the insured party. Ensure that the values entered are correct as a transaction will be deducted from your allotted count whether a beneficiary is found or not.

Enter either the Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]) or SSN. Since Medicare IDs can change for a particular beneficiary, the lookup can result in a match but a different Medicare ID may be returned.

The first initial of the first name, first six characters of the last name, gender, and date of birth comprise the secondary part of the match. Once a record is found for the Medicare ID or SSN, then at least 3 out of 4 of these other personal characteristics must also match the beneficiary record for the insured party to be considered a match. If you do not have the Medicare ID available or are unsure of the validity of the Medicare ID, the SSN may be entered instead; NGHP and GHP reporters may enter either the last 5 or the full 9 digits.

Once entered, click Continue to show the Beneficiary Lookup Response fields below the input fields. The matched values returned to all RREs are based on the matched values found in the beneficiary database. If there is no value for a field, the field will show as blank. The information returned will depend on whether the RRE is set up to report GHP or NGHP information. Prescription drug (Part D) coverage information will appear on the response only if RREs report prescription drug coverage for the beneficiary.

Transactions Remaining – NGHP RREs that have not selected the Direct Data Entry (DDE) reporting option are allotted 500 transactions per month. This number represents the number of transactions still available for use. This counter will be automatically reset each month. Requests for additional transactions should be directed to your EDI representative. GHP RREs can submit an unlimited number of queries.

Fields marked online with an asterisk (*) are required.

Table 1: Beneficiary Lookup

Field	Description
Medicare ID or SSN	Enter the insured party's Medicare ID (HICN or MBI) assigned by Medicare or their SSN. Valid Medicare IDs may consist of up to 12 characters. If the Medicare ID is not available an SSN may be entered instead. Valid SSNs consist of 9 numeric digits or the last 5 digits of the SSN. (Note: When entering 5 digits, there is no need to add any leading spaces.) Note: Medicare ID is also known as the Medicare Number to CMS’ Medicare beneficiaries.
First Name	Enter the first name of the insured party. May contain letters A-Z or a-z and embedded spaces. Enter name as shown on Social Security card or Medicare card.
M.I.	Enter the first letter of the insured party's middle name. Enter one alphabetic character (optional).
Last Name	Enter the last name of the insured party. May contain letters A-Z or a-z, hyphens, apostrophes and embedded spaces. Enter name as shown on Social Security card or Medicare card.
Gender	Select the gender of the insured party as Male or Female.
Date of Birth	Enter the birth date of the insured party. Enter numeric digits 0-9 in MM/DD/YYYY format.
Cancel	Click to return to the RRE Information Detail page without performing the lookup. The information you entered will not be saved.
Continue	Click to submit the information for verification. If the information is correct, the Beneficiary Lookup Response will appear below the input fields. If not, the Beneficiary Not Found error appears.
Clear	Click to remove all entered data.

Table 2: Response Fields (NGHP)

Field	Description
Most Recent Medicare Entitlement Information	This section shows the most recent instance of entitlement for the given Medicare Part, if any, within the last three years.
Medicare ID	Medicare ID of the beneficiary.
First Name	First name of the beneficiary.
M.I.	Middle initial of the beneficiary, if available.
Last Name	Last name of the beneficiary.
Gender	Gender of the beneficiary.
Date of Birth	Date of birth of the beneficiary.
Part A Effective Date	Start date of the beneficiary’s most recent Medicare Part A (Hospital) entitlement period.
Part A Termination Date	End date of the beneficiary’s most recent Medicare Part A (Hospital) entitlement period, if applicable.
Part B Effective Date	Start date of the beneficiary’s most recent Medicare Part B (Physician) entitlement period.
Part B Termination Date	End date of the beneficiary’s most recent Medicare Part B (Physician) entitlement period.
Part C Contract Number	Contract number for the beneficiary’s most recent coverage (within three years).
PBP Number	Number of the Plan Benefit Package for the beneficiary’s most recent coverage.
Part C Effective Date	Start of the beneficiary’s most recent Part C coverage.
Part C Termination Date	End date of the beneficiary’s most recent Part C coverage.
Contract Name	Name of the Part C contractor.
Address 1	First line of the contractor’s address.
Address 2	Second line, if any, of the contractor’s address.
City	Contractor’s city.
State	Contractor’s state.
ZIP	Contractor’s ZIP code.
Part D Contract Number	Contract number for the beneficiary’s most recent Part D coverage.
PBP Number	Number of the Plan Benefit Package for the beneficiary’s most recent Part D coverage.
Part D Effective Date	Start date of the beneficiary’s most recent Medicare Part D coverage.
Part D Termination Date	End date of the beneficiary’s most recent Medicare Part D coverage.
Contract Name	Name of the Part D contractor.
Address 1	First line of the contractor’s address.
Address 2	Second line, if any, of the contractor’s address.
City	Contractor’s city.
State	Contractor’s state.
ZIP	Contractor’s ZIP code.
Part C History	This shows up to 12 of the most recent instances of entitlement data for the beneficiary for the last three years of entitlement with the most recent dates at the top.
Contract Number	Contract number for the beneficiary’s most recent Part C coverage.
PBP Number	Number of the Plan Benefit Package for the beneficiary’s most recent Part C coverage.
Effective Date	Start date of the beneficiary’s most recent Medicare Part C coverage.
Termination Date	End date of the beneficiary’s most recent Medicare Part C coverage.
Contract Name	Name of the Part C contractor.
Address 1	First line of the contractor’s address.
Address 2	Second line, if any, of the contractor’s address.
City	Contractor’s city.
State	Contractor’s state.
Zip	Contractor’s ZIP code.
Part D History	This shows up to 12 of the most recent instances of entitlement data for the beneficiary for the last three years of entitlement with the most recent dates at the top.
Contract Number	Contract number for the beneficiary’s most recent Part D coverage.
PBP Number	Number of the Plan Benefit Package for the beneficiary’s most recent Part D coverage.
Effective Date	Start date of the beneficiary’s most recent Medicare Part D coverage.
Termination Date	End date of the beneficiary’s most recent Medicare Part D coverage.
Contract Name	Name of the Part D contractor.
Address 1	First line of the contractor’s address.
Address 2	Second line, if any, of the contractor’s address.
City	Contractor’s city.
State	Contractor’s state.
Zip	Contractor’s ZIP code.

Table 3: Response Fields (GHP Basic or Expanded)

Field	Description
Most Recent Medicare Entitlement Information	This section shows the most recent instance of entitlement for the given Medicare Part, if any, within the last three years.
Medicare ID	Medicare ID of the beneficiary.
First Name	First name of the beneficiary.
M.I.	Middle initial of the beneficiary, if available.
Last Name	Last name of the beneficiary.
Gender	Gender of the beneficiary.
Date of Birth	Date of birth of the beneficiary.
Date of Death	Date of the beneficiary’s death in MM/DD/YYYY format, if applicable.
Entitlement Reason	Reason for the beneficiary’s entitlement.
Part A Effective Date	Start date of the beneficiary’s most recent Medicare Part A (Hospital) entitlement period in MM/DD/YYYY format.
Part A Termination Date	Termination date of the beneficiary’s most recent Medicare Part A (Hospital) entitlement period in MM/DD/YYYY format, if applicable.
Part B Effective Date	Start date of the beneficiary’s most recent Medicare Part B (Physician) entitlement period in MM/DD/YYYY format.
Part B Termination Date	Termination date of the beneficiary’s most recent Medicare Part B (Physician) entitlement period in MM/DD/YYYY format.
Part C Enrollment Date	Start of the beneficiary’s most recent enrollment in a Medicare Health Maintenance Organization (HMO) plan.
Part C Termination Date	Termination date of the beneficiary’s most recent enrollment in a Medicare HMO plan.
ESRD Coverage Start Date	Start date of the beneficiary’s most recent End Stage Renal Disease (ESRD) coverage, if applicable.
ESRD Coverage End Date	End date of the beneficiary’s most recent ESRD coverage, if applicable.
1st Dialysis Date	Date of the beneficiary’s first dialysis, if applicable.
Transplant Date	Date of the beneficiary’s transplant, if applicable.
Transplant Failure Date	Date of the beneficiary’s transplant failure, if applicable.
Self-Training Date	Date of the beneficiary’s self-training, if applicable.
Medicare Secondary Payer Coverage Row(s)	Displays the effective date and termination date of the beneficiary’s Medicare Secondary Payer Coverage in MM/DD/YYYY format. Notes: Effective date will display first, followed by a dash, then the termination date. If there is no termination date, the space after the dash will be blank. If there is more than one period of coverage, the dates will display chronologically starting with the oldest.

September 2024

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