ENROLLMENT AND ELIGIBILITY DATA

INTRODUCTION

To support Medicare program administration functions, CMS (previously HCFA) maintains person-level enrollment and eligibility records for the entire Medicare population. Each time a claim for services rendered is received for adjudication and payment, beneficiary entitlement status is verified using this information. CMS maintains separate databases that collectively store all the enrollment and entitlement information necessary to complete administrative functions. With the implementation of the Enrollment Database (EDB), CMS has started replacing these separate databases with one central repository of Medicare beneficiary enrollment records. All of the files discussed in this chapter contain enrollment and eligibility data that originate from Medicare administrative functions. The Enrollment and Eligibility Data chapter contains two file groups:

The EDB is the designated CMS repository of enrollment and entitlement data. The Other Enrollment Files group includes the Third Party (TPEARTH) Master File, the Group Health Plan (GHP) Master File, the Health Insurance Skeleton Eligibility Write-off (HISKEW) File, the Denominator File, and the Name and Address File. The first file contains information on beneficiaries whose premiums are paid by third parties. As of August 30, 1996, direct billing data, i.e., beneficiaries who pay their own premiums, have been integrated into the EDB. The GHP Master File contains information on beneficiaries enrolled in and receiving Medicare covered services from Managed Care Organizations (MCO). The HISKEW File contains an abbreviated format of the EDB records. The fourth file, the Denominator File, combines beneficiary information from the EDB and the TPEARTH Master File. The TPEARTH Master File may be integrated into the EDB by the end of 2000. The Name and Address File is a subset of the data elements of the EDB.

Enrollment and Eligibility Introduction | Enrollment Database | Other Enrollment Files