In Order to Obtain Access to Eligibility Data, Provider Agrees to the Following

MEDICARE ACCESS FORM

______, (insert Provider/Customer name), using the National Provider Identifier(s) (NPIs) below, designates Passport Health Communications, Inc. as their vendor to access Medicare Part A / Medicare Part B eligibility data on Provider’s behalf.

In order to obtain access to Medicare Part A / Part B eligibility data, Provider confirms that they are a valid Medicare Part A or Part B healthcare provider that holds a valid Medicare NPI.

Per The Centers for Medicare and Medicaid Services (CMS) Rules of Behavior regarding access to Medicare Part A / Medicare Part B eligibility data, Provider agrees to the following:

• Before requesting Medicare beneficiary eligibility information and at all times after, Provider will ensure sufficient security measures to associate a specific transaction with the specific user (whether employee or agent);

• Provider will cooperate with CMS or its agents in the event that CMS has a security concern with respect to any eligibility inquiry;

• Provider will promptly inform CMS or one of CMS’s contractors in the event a misuse of “individually-identifiable” health information accessed from the CMS database is identified; and

• Each eligibility inquiry will be limited to requests for Medicare beneficiary eligibility data with respect to a patient currently being treated or served by Provider, or who has contacted Provider about treatment or service, or for whom the Provider has received a referral from a health care provider that has treated or served that patient.

Provider also agrees to access eligibility information in accordance with the following purposes authorized by CMS:

• Verify eligibility for Medicare Part A / Medicare Part B;

• Determine beneficiary payment responsibility with regard to deductible/co-insurance;

• Determine eligibility for services such as preventive services;

• Determine if Medicare is the primary or secondary payer;

• Determine if the beneficiary is in the original Medicare plan, a Part C plan (Medicare Advantage) or a Part D plan; and

• Determine proper billing.

Passport is operating as a vendor agent for Provider, its records, databases, and systems with respect to Medicare Part A / Medicare Part B. Passport is subject to random auditing by CMS, any authorized representative of the State of Tennessee, the U.S. Department of Health, or the U.S. General Accounting Office or their authorized representatives, and that upon confirmation of contract violations, CMS or the State of Tennessee as its agents may require appropriate corrective action and/or terminate access to eligibility data, depending on the nature and degree of the violation.

Provider agrees that Passport has the right, for the purpose of verification, to request a copy of, inspect, examine, and conduct an audit of each of Provider’s Electronic Data Interchange (EDI) Enrollment Forms or Electronic Remittance Advice that confirms Provider’s access to Medicare Part A / Medicare Part B funds. Provider also agrees to make those records available for such inspection within 48 hours of receiving the request from Passport. Passport reserves the right to terminate access to Medicare Part A / Part B eligibility data set forth in this addendum upon confirmation of contract violations.

NPI #:

I am authorized to sign this document on behalf of the Provider. I have read and agree to the provisions referenced herein and acknowledge such by signing below.

ACCEPTED AND AGREED TO:

Customer:
Signed By:
Print Name:
Title:
Facility:
Date: