Yikes. I’ve been hacked!!!!

May 12, 2015

Google recently notified me that the site has been hacked. Luckily the hackers didn’t completely hijack the site but I may need to take it down for a couple of days to do some clean up. I’ll try to give you some notice before taking everything offline.  Sorry everyone. I’ll keep you posted on the outcome.

Prefix List Update, Anthem Breach, Cigna Purchases Qualcare

February 5, 2015

Prefix List Update

This weekend I’m planning to replace the existing prefix lists with a brand new list. There are still some changes that need to be made but I didn’t want to hold it up any longer. There are a few things to note about the new list:

1. The pages will be organized a little differently than the current pages. All the prefixes for a particular letter of the alphabet will be on one page. Hopefully this will make it easier to find what you need and it will make it easier for me to update.

2. There were hundreds of prefixes on the new list that are no longer assigned to a plan but were in the past. I’ve left those on the site for now. They’re labeled “unassigned” where the plan name should be. If you think leaving them on the list adds clutter let me know and I can remove them.


Aetna Eligibility Issues with Walmart Members

January 13, 2015

Please see the update below from Aetna regarding checking eligibility for Walmart members. Evidently you can only check eligibility for them electronically using the name and DOB.


We’d like to let you know that using certain search criteria, users are unable to get successful real-time eligibility and benefits responses for Walmart members.


Using certain search criteria, users attempting to get eligibility and benefits details for Walmart members are receiving an error code of “Subscriber/Insured Not Found” (AAA75).

— To receive a successful response, users can use the Name/date of birth search option.

— The following search criteria will not return a successful response, that is, using these search criteria will return an error:

– Walmart ID/date of birth
– Walmart ID/name
– Walmart ID/name/date of birth

We’re in the process of identifying the root cause of this issue. We’ll send additional information after we’ve determined how to correct this issue.

CMS Looking for Volunteers for ICD 10 Testing

September 22, 2014

CMS posted the following update on Friday and the deadline is coming soon if you’re interested in participating. Sounds like an interesting opportunity.


Volunteers Sought for ICD-10 End-to-End Testing in January: Forms due October 3

January 26-30, 2015

During the week of January 26 through 30, 2015, a sample group of providers will have the opportunity to participate in ICD-10 end-to-end testing with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor. The goal of end-to-end testing is to demonstrate that:

  • Providers and submitters are able to successfully submit claims containing ICD-10 codes to the Medicare Fee-For Service (FFS) claims systems
  • CMS software changes made to support ICD-10 result in appropriately adjudicated claims
  • Accurate Remittance Advices are produced



CoventryCare Medicaid PA Migration, CMS HETS Eligibility Change

September 18, 2014

A couple of quick updates for this week:

CoventryCares to Aetna Better Health of PA Migration

Coventry Care of Pennsylvania will be migrating their Medicaid business to Aetna Better Health effective 10/1/2014. New cards are being sent out with the new payer ID and claim address. See the top of page two of their newsletter.


I’ve see several member notifications but very little to the providers. I’ll keep you posted as they provide more info.

CMS Date of Service Change

CMS will be changing how far in the past they will allow eligibility requests. Effective 9/28, CMS will begin limiting inquiries to 12 months in the past (vs 27 months which you can do now). Any transactions requesting eligibility through HETS with old dates of service will get rejected.

HETS Eligibility Release Summary for September 2014

CMS Posts Reminder to Marketplace Members on 9/30 deadline.

CMS posted another update to Healthcare.gov regarding providing proof of income and citizenship in order to keep coverage through the marketplace. The deadline is 9/30.



Health Exchange Market Place, Medicare Inpatient Claim Appeals, Site Updates

September 9, 2014

CMS may end Health Insurance Market Place coverage for thousands due to data inconsistencies.

CMS sent an interesting press release a few weeks ago regarding a letter they sent to 300,000 health exchange members. These members need to provide additional information or clarify information from their original application. If they don’t respond, coverage for these members will end on 9/30/2014.


CMS Offering Payment on Inpatient Claims Pending Appeal

CMS is actively updating this article they posted regarding the measures they’re taking to reduce the number of appeals they have pending for inpatient stays. As I’m writing this, there’s a teleconference to explain the process. Evidently acute care facilities are eligible for a reduced payment of their charges if they withdraw their appeal.

Site Updates

I just added the most recent Medicare Advantage payer lists and I’ve added links to them in the side bar. Please let me know if you have any trouble downloading them.


Community Health Systems Massive Data Breach

August 19, 2014

I’m sure most of you have already seen this but it popped into my inbox three times this week so I thought I would share. This is the article from Modern Healthcare.

Chinese hackers hit Community Health Systems; others vulnerable

An outside group of hackers targeted Community Health Systems’ computer network and stole 4.5 million individuals’ nonmedical patient data, the company disclosed Monday in a regulatory filing.

The Franklin, Tenn.-based chain, which says it has 206 hospitals in 29 states, said a group originating in China used highly sophisticated malware and technology in the criminal attack. It believes the hackers were searching for intellectual property on medical devices and other equipment, but instead stole data on patients who sought care from its physician practices.


Coventry/Aetna Conversion, Wellpoint Name Change, Medicare Therapy Caps

August 15, 2014

It’s been way too long since I’ve done an update. A few interesting things have crossed my desk lately so I thought I would share.

CoventryCares of Nebraska migrates to Aetna Better Health on 8/24/2014.

It looks like Aetna is finally starting to integrate Coventry into their business. We first thought this was just a rebranding to get rid of the Coventry name but this appears to be a true conversion. This is part of the announcement that Emdeon posted yesterday:

The membership of CoventryCares of Nebraska (currently sent using real-time Payer ID 00511) is expected to migrate August 25, 2014 to Aetna Better Health of Nebraska (new real-time Payer ID ABHNE). With this migration, users will no longer have access to the provider look-up functionality unique to the CoventryCares of Nebraska transactions.

Effective on that date, real-time transactions for these plans will need to be submitted using the new plan name and/or real-time payer ID information: Aetna Better Health of Nebraska, real-time payer ID ABHNE. During the time of August 19, 2014 through August 24, 2014, Health Care Services Review – Request for Review and Response 278 transactions submitted to either real-time payer ID, 00511 or ABHNE, will receive an error message indicating the system is unavailable. All Health Care Services Review – Request for Review and Response 278 transactions should be held during this time and resubmitted to real-time payer ID ABHNE beginning August 25, 2014.

Beginning September 25, 2014, Eligibility Inquiry and Response 270/271, Claim Status Inquiry and Response 276/277 and all Health Care Services Review 278 transactions submitted to the legacy plan name (CoventryCares of Nebraska) and/or legacy real-time payer ID (00511) will receive an error message in the response reminding the submitter to re-submit under the new plan name/real-time payer ID.

I expect to see more of these coming soon. I’m hoping Aetna will provide some type of conversion schedule.

Wellpoint Changes Name to Anthem

I’m not sure what this will mean for ID cards and plan names for plans like BCBS of Wisconsin and Empire BCBS. I’m hoping this is just a marketing ploy with very view real world changes.

Wellpoint Name Change

Medicare Therapy Caps Not Updating Correctly

I’ve heard a rumor that there are issues with therapy claim dollars getting applied to beneficiary therapy cap amounts. My understandings is that neither HETS and DDE are showing the correct amounts and you must call your MAC to get the right amounts. If you’ve heard anything about this or talked to our MAC, please leave a comment below.

CMS, North Carolina Medicaid, United Community Plan of PA updates

April 3, 2014

There’s a lot happening in payer land right now. These are a few of the things that have crossed my desk.

1. Of course as soon as I published the post on Medicare DDE being shutdown this week, CMS postponed the date. The announcement is very vague about when it will be shut down but the rumor is that it won’t go away until 2015.

2. CMS has a release scheduled for this weekend that will add psych and historical hospice data to the Medicare eligibility response. They’ve attempted to add this several times but have had to roll it back each time. I’m keeping my fingers crossed that it will stick this time.

*Update 12:45 4/3/2014 – CMS just announced that this was postponed until 4/12.*

HETS Eligibility Release Notes

3. North Carolina Medicaid made changes to the eligibility response on 3/22 to be CORE complaint. One of the changes was that they stopped telling you if the recipient was actually eligible. They were bombarded with complaints and made another change on 3/29 to “fix” it. I suspect there will be other changes coming up soon.

Updates to Recipient Eligibility Inquiry and Claim Status for CAQH CORE Announcement

4. H.R 4302 was signed by President Obama Tuesday. This bill will delay the implementation of ICD 10 until 2015 as well as delay the Sustainable Growth Rate fee structure for Medicare payments.

5. UHC migrated the United Community Plan members from the old Americhoice PA system to the United Healthcare system effective 3/1/2014. For dates of service after 3/1, you will need to use United Healthcare Online to check eligibility (or your EDI vendor) but you will need to use the United Healthcare Community plan portal for dates prior to 3/1. Also the new claims payer ID will be 87726 for dates after 3/1.

New Prefixes Added

March 27, 2014

I wanted to thank everyone that has sent me new prefixes to add to my list. Please keep them coming.  I did some digging and the Wellpoint plans have published the new prefixes for the health exchange plans. I added those yesterday along with a few more I’ve found. I still have another handful that I’ll add in a few days.

As I’m adding them, I’m changing the format of the tables to make them a little easier to deal with. Please note that the new tables can only display up to 100 lines at a time. If you don’t see the prefix you’re looking for, you may need to go to the next page.


Newly added: