Medicare No claims/payment information FAQ

Q: Why can’t I access claims or payment information for an individual practitioner from our organization?

A: Access to claims, payment, and analytical data is based upon how your organization bills Medicare. Claims and payment information will not return for an individual unless he or she bills Medicare as a separate entity.

Access to claims, payment, and analytical data through ‘the SPOT’
The return of claims, payment, and analytical information through the SPOT is based upon the following:
• How your organization bills Medicare
• The profile associated with your EIDM SPOT access profile (i.e., default profile) and/or the additional profile selected on the SPOT -- through the Profile Menu -- when the query was submitted

Organizations that bill Medicare as a single billing entity

If your organization bills Medicare as a group, professional association, or corporation, then claims, payment, and analytical data will only be accessible for the billing entity not for each individual practitioner -- even if your practice only has one practitioner.

The provider-specific information (NPI, PTAN, TIN, and Practice Official’s identity/role) associated with your EIDM SPOT access profile should be based upon how your organization bills Medicare.

• Organizations that bill Medicare as an entity should have the group, professional association, or corporation’s NPI/PTAN/TIN and practice official for that organization in the default account profile associated with the EIDM SPOT access profile.

Multiple practitioners who belong to an organization but bill Medicare separately

If each practitioner in your organization bills Medicare separately, then claims, payment, and analytical data for each of those practitioners will be accessible by creating additional profiles within the SPOT.
• If multiple providers belonging to the same organization each bills Medicare separately, then each individual practitioner’s provider-specific information should be listed in a profile associated with an additional profile within the SPOT.
• To learn how to create an additional profile within the SPOT

Individual practitioners who bill Medicare under personal SSN/TIN

If a single provider bills Medicare under his or her own personal SSN/TIN, then claims, payment, and analytical data for that individual will be accessible as long as the default profile associated with the EIDM SPOT access profile reflects the provider-specific information for that provider.
• If a single provider bills Medicare under his or her own personal SSN/TIN, the individual practitioner’s provider-specific information should be listed in the profile associated with the EIDM SPOT access profile.

How to correct your default profile
To update the default profile associated with your EIDM SPOT access profile to reflect your organization’s NPI, PTAN, TIN, and Practice Official information, just follow the steps outlined in the Modify account profile FAQ, and you will be able to receive the claims and payment information your need for your organization through the SPOT.

Tip: Before you begin, please check your organization’s official enrollment record in Internet-based PECOS external link to ensure that you have the correct name and exact role of the practice official listed.

When you submit your profile modification request, it will be compared to the organization’s official enrollment record in PECOS. If any of the information does not match the official PECOS record, including the name and role of the practice official, the profile modification request will be denied.