How To Verify Medicare Coverage: Guide for Checking Eligibility

Getting Medicare certification for your facility felt hard enough, and now verifying Medicare coverage for patients is getting complicated — but it doesn’t have to be. Whether you're confirming eligibility for incoming patients or making sure specific services will be reimbursed, the right tools simplify the process.

Here’s how you can efficiently verify Medicare coverage, understand eligibility criteria clearly, and access resources that keep your admissions process running smoothly.

In this article, we’ll cover:

• How to verify Medicare coverage

• Medicare eligibility criteria

• Methods to verify Medicare coverage

• Tools and resources for checking eligibility

What to know about Medicare eligibility criteria

Accurately verifying Medicare eligibility is the first step toward smoother patient admissions — and fewer Medicare billing headaches — for your facility. Missed details about a patient's Medicare status often lead to denied claims, delayed reimbursements, and strained relationships with hospitals.

But understanding exactly who qualifies, and when, can change all that. Let's dive into the specific criteria for Medicare eligibility so you can confidently streamline admissions, improve financial forecasting, and keep your facility running efficiently.

Age-based eligibility

Medicare eligibility starts with age. Anyone aged 65 or older who's a U.S. citizen or permanent resident qualifies automatically. But age alone doesn't guarantee immediate coverage — you'll still need to confirm enrollment status to avoid surprises during admission. 

Are you regularly verifying eligibility for your senior patients? Getting into a habit of confirming eligibility upfront helps prevent costly billing issues later.

Disability-based eligibility

Not every Medicare recipient is over 65. Patients under 65 can also qualify after receiving Social Security Disability Insurance (SSDI) benefits for at least 24 consecutive months. This group often gets overlooked, yet they're frequently referred from hospitals needing post-acute care.

Is your admissions team routinely checking SSDI status for younger patients? Recognizing disability-based eligibility ensures smoother transitions and quicker admissions decisions.

Additionally, Medicare provides immediate eligibility (without the 24-month waiting period) for individuals diagnosed with specific conditions:

• End-stage renal disease (ESRD): Patients undergoing dialysis or awaiting kidney transplants.
  
  

• Amyotrophic lateral sclerosis (ALS): Patients diagnosed with ALS receive automatic Medicare coverage immediately upon SSDI approval.

These exceptions make accurate eligibility checks critical, especially when handling urgent referrals.

How to check if a specific service is covered by Medicare

Even if a patient is eligible, verifying whether specific treatments, medications, or procedures are covered is crucial for accurate billing. Medicare’s online coverage tool at Medicare.gov allows providers to quickly check if a particular service or item is reimbursable.

Before committing resources, simply enter the test or service details into the tool — saving your facility from unexpected costs or denied claims down the road.

How to verify Medicare coverage in 3 steps

Verifying Medicare coverage isn’t just a box to check — it’s the key to avoiding billing headaches and ensuring a smooth admissions process. Whether you’re confirming a patient’s overall eligibility or checking if a specific service is covered, a few essential steps can make the process faster and more reliable. Here’s how to do it efficiently.

Step 1: Use Medicare’s online coverage tool

Before making an admissions decision or scheduling a service, the first step is checking whether Medicare will cover the treatment, procedure, or equipment a patient needs. Medicare.gov provides an easy-to-use tool called “Is my test, item, or service covered?”

Here’s how it works:

• Visit Medicare.gov.

• Enter the name of the service, test, or item in question.

• Review coverage details, including any conditions or limitations.

This step is particularly useful for verifying specific services like skilled nursing care, durable medical equipment, and therapy services — helping your team avoid costly coverage surprises.

Step 2: Confirm eligibility with the Social Security Administration

Once you’ve checked coverage for specific services, the next step is verifying whether a patient is actually enrolled in Medicare. While hospitals typically send referral packets with insurance details, it’s always a good idea to double-check the patient’s status.

To do this, contact the Social Security Administration (SSA) by calling 1-800-772-1213. This line allows healthcare providers to:

• Confirm a patient’s Medicare enrollment status.

• Check whether they have Part A (hospital insurance) or Part B (medical insurance).

• Identify any coverage start dates or gaps.

This is especially important for patients who are new to Medicare or those whose coverage may have lapsed due to non-payment or other reasons.

Step 3: Use Medicare Administrative Contractors (MACs) for provider-level verification

For facilities handling multiple Medicare admissions, relying on Medicare Administrative Contractors (MACs) can be a more efficient way to verify patient eligibility. MACs operate online provider portals that allow skilled nursing facilities and post-acute care providers to check eligibility directly.

Each region has a designated MAC portal, which your facility should be registered with. Through these online portals, you can confirm patient eligibility, verify enrollment status, and review coverage details in real time.

This method provides a more streamlined way to ensure that Medicare claims are processed correctly.

*Please note: From March 31, 2025 on, providers will no longer be able to verify Medicare eligibility by calling MACs and using their automated phone systems. Facilities will have to rely on other methods like the secure online portals, software vendors, or other Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction systems.

Using a combination of these steps ensures that your facility has accurate and up-to-date Medicare coverage information before making admissions or billing decisions. A well-organized verification process helps prevent delays, reduce claim denials, and keep your financials on track.

How to check Medicare eligibility

When verifying Medicare eligibility, having the right details at your fingertips speeds up the process and helps avoid delays or mistakes. Here's the essential information you’ll typically need:

• Patient’s full name exactly as it appears on their Medicare card

• Medicare Beneficiary Identifier (MBI)

• Date of birth

• Social Security Number (if MBI isn’t immediately available)

• Coverage start dates and current Medicare enrollment status

Having this information ready before you need to check Medicare eligibility ensures a quick, accurate verification process, making your admissions workflow smoother.

How do I find my Medicare Beneficiary Identifier (MBI)?

Every Medicare recipient is assigned a unique Medicare Beneficiary Identifier (MBI) — the key to verifying eligibility efficiently. You can usually find the MBI clearly printed on the patient’s Medicare card. If the patient doesn’t have their card available, you can:

• Check hospital referral packets, which typically include the MBI.

• Contact the Social Security Administration (SSA) at 1-800-772-1213 to request the patient’s MBI, using their Social Security Number and personal details to confirm identity.

Quick access to the MBI ensures faster processing of patient admissions and smoother billing.

Online tools for checking Medicare eligibility

MyMedicare.gov account

Patients or providers authorized by the patient can quickly confirm coverage details through MyMedicare.gov. This Medicare login lets you view personalized coverage information, including details on active benefits, Medicare enrollment status, and plan specifics.

Regularly using MyMedicare.gov helps providers stay updated on patient coverage.

HIPAA Eligibility Transaction System (HETS)

For healthcare providers, the HIPAA Eligibility Transaction System (HETS) is a reliable online tool designed specifically to verify Medicare eligibility. Accessing HETS requires approved credentials, and it provides real-time eligibility status, ensuring accuracy and reducing potential billing issues.

Third-party services

Third-party billing agencies and clearinghouses also offer eligibility verification services. These can streamline the process by consolidating multiple verifications into a single workflow.

ExaCare stands out among these third-party options by offering an AI-powered platform specifically designed for skilled nursing facilities and post-acute care providers. It integrates seamlessly with referral portals like EPIC Link, automatically extracting and summarizing key patient eligibility details.

This means your admissions team spends less time verifying coverage and more time making informed admissions decisions — enhancing operational efficiency and improving relationships with referring hospitals.

Understanding your Medicare coverage

Hospital insurance (Medicare Part A)

Medicare Part A covers inpatient hospital stays, care at skilled nursing facilities, hospice care, and certain home health services. During admissions, accurately identifying covered resources is critical to avoid costly billing errors or denied claims.

ExaCare helps by automatically summarizing clinical details from referral packets, clearly identifying a patient’s specific hospital insurance coverage. This reduces confusion and speeds up your admissions decisions, ensuring you’re prepared for reimbursement.

Medical insurance (Medicare Part B)

Medicare Part B covers outpatient care, doctor visits, preventive services, and certain medical supplies. Verifying these specifics is crucial for planning patient care.

ExaCare simplifies this process by extracting coverage details directly from referral documents, clearly outlining the patient’s Part B eligibility. This ensures your clinical team understands exactly what's covered, helping avoid surprises down the line.

Medicare Advantage (Medicare Part C)

Medicare Advantage plans offer coverage through private insurers, often including additional benefits beyond Original Medicare. Because these plans can differ significantly in what they cover, verifying eligibility and coverage specifics is particularly important.

ExaCare supports your admissions team by clearly summarizing key Medicare Advantage details — such as plan rules and coverage limits — so you know precisely what care is approved and how it will impact reimbursement decisions.

Prescription drug coverage (Medicare Part D)

Medicare Part D provides prescription drug coverage through private insurers, and accurate verification here is critical, especially when admitting patients who require expensive medications.

ExaCare automatically highlights prescription medication coverage directly from referral information. This ensures your facility can accurately forecast medication costs, anticipate reimbursement, and manage patient care without financial uncertainty.

Frequently asked questions 

How often should I check my Medicare eligibility status?

You should verify Medicare eligibility each time you admit a patient or when there’s a change in their Medicare coverage, to ensure you have accurate information for billing and care planning.

What should I do if my Medicare coverage information is incorrect?

If Medicare coverage details appear incorrect, contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) or reach out to the Social Security Administration at 1-800-772-1213 immediately to correct any discrepancies and avoid billing issues.

Can I verify Medicare eligibility for someone else?

Yes, healthcare providers, authorized representatives, or facility staff who handle patient admissions can verify Medicare eligibility for patients, provided they have the necessary patient details such as name, Medicare Beneficiary Identifier (MBI), date of birth, or Social Security Number.

Is your nursing home ready to simplify Medicare verification?

We hope this guide helps you with how to verify Medicare coverage. Many nursing homes still rely on manual Medicare eligibility checks, combing through lengthy referral documents and managing multiple verification tools.

This approach not only slows your admissions process but also risks inaccuracies that can hurt your facility financially and damage hospital relationships.

Adopting a platform like ExaCare can dramatically simplify your eligibility verification, giving you instant access to clear, accurate patient information — helping your facility admit patients quickly, reduce billing errors, and strengthen your position as a trusted hospital partner.

Our platform helps you modernize your operations while maintaining the quality of care your facility is known for.

Here’s what we offer:

• AI-powered referral screener that reviews hospital packets in minutes, enabling quick and accurate admissions decisions
  
  

• Centralized referral management that brings all your sources into one platform
  
  

• Built-in analytics to help you track performance and optimize your referral relationships
  
  

• Automated insurance verification, expensive med alerts, and reimbursement analyses to guard your bottom line.
  
  

•  A unified communication hub to streamline decision-making with colleagues.

Ready to see how ExaCare can help your facility win more referrals? Talk with our team to learn more.

Schedule a demo.