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:


Termination of Medicare Common Working File – April 7th

February 11, 2014

CMS recently released an update to the announcment that the CWF eligibility transactions will be sunset in 2014. The target date is April 7th to discontinue HIQA, HUQA, HIQH, ELGA, and ELGH. If you haven’t switched to using HETS either directly from Medicare or through a vendor, it’s definitely time to start looking for an alternative.

CMS announcement regarding the demise of the CWF:




The Affordable Care Act and Patient Eligibility

January 15, 2014

It seems like I can’t open my email without seeing something about the Affordable Care Act and how it’s going to affect checking patient eligibility. We really hoped that the larger payers that were going to participate as healthcare exchange plans would be on top of things but that hasn’t been the reality.

What we’ve seen so far :

1. Some health plans did not have ACA members loaded as timely as we had hoped. Some are loading the bare minimum with the intentions of loading benefits later.

2. ACA members aren’t being clearly identified in the EDI eligibility responses by some insurance companies.

3. We still aren’t getting a clear picture of how the 90 day grace period is going to be represented in eligibility responses. A couple of payers have implemented very clear messages indicating that the person is within their 90 period but most have not.

The good news is that most payers are still making changes to accomodate the ACA membershship and we expect to see some improvements in February and March. I’ve already seen notifications from at least two large plans that they will be making changes in February to help clarify where the member is in relation to their grace period. I’ll post these changes as I get them.




Acquisitions: Passport Health Communications and HMA

November 6, 2013

A couple of interesting acquisitions in healthcare land. It was announced today that Experian (yes credit reporting Experian) is aquiring Passport Health Communications for alot of money.

Experian to buy Passport Health Communications for $850 Million.

This was announced a while ago but it’s still interesting. CHS is buying HMA. Once this deal has closed, they will have a total of 209 hospitals nationwide.

Community Health Systems to buy HMA


Site updates

October 1, 2013

Over the next few weeks you’ll notice format changes on the prefix pages. The way the tables are loaded currently, adding additional prefixes is somewhat of a nightmare. I’m going to be converting those pages into a different style of table so they’ll be easier to update. Also I’m looking for someone to help me update them monthly so you’ll see more frequent changes/additions.

If there are prefixes you would like to have added, please send them through Contact Us (it’s in the footer).

Health Insurance Exchanges – Feedback Needed.

October 1, 2013

I can’t believe it’s already October 1st. Health insurance exchanges will go into effect today and I’m curious how this will effect your business. If you have a few minutes I would love to get your feedback on these questions.

1. Did you get any training on insurance exchanges?
2. How is your office/facility preparing for patient’s enrolled in HIEs?

Aetna Eligibility Issue 8/26/2013

August 26, 2013

Aetna just out a message about a problem with members that have a foreign address. I thought I would pass it on.


“Our Eligibility and Benefits Inquiry transaction can’t return eligibility responses when the member has a foreign address. Providers will see one of the following responses:

•           An incomplete response, where the state, postal code and country code fields are blank, or

•           A “Required application data missing” error message


Transactions submitted with an inquiry date of 1/1/2013 or later will return the AAA15 error message.


As a workaround, providers who are unable to get a complete response for foreign members can call Aetna’s Provider Service Centers at 1-888-MD-AETNA (1-888-632-3862) for complete eligibility information.”

Aetna EDI Changes Effective August 9th

August 14, 2013

Many of you have probably already received this from Aetna but I thought I would still pass it on. Aetna had a release last week and fixed some long standing bugs. Below is an exerpt of the announcement they sent out regarding the release.

Eligibility Transaction Changes

1. We’ll remove the following messages, which are no longer needed:

o The “Age Limit Applies” message is no longer needed, as we give the actual ages in our response when limits apply.

o The “Applies to HMO provider” message is not needed, as we no longer have a need to limit benefits specifically for HMO providers.

2. In support of Safe Harbor guidelines, which provides contraceptive supplemental coverage through a separate plan with Aetna listed as the plan sponsor, we’ll:

o Issue two Member ID cards, one for the base medical plan and one for the supplemental contraceptive coverage plan.

o Return a message within the eligibility transaction to direct providers to the appropriate plan when necessary to obtain benefits.

3. We’ll add a message when some Not Covered responses are returned.

Message examples:

Benefits may be available. Please inquire under member’s medical plan

Please inquire under member’s medical plan

Member does not fall within the age limitations for this benefit


CHS, Oregon Medicaid, United Health Community Plan

August 2, 2013

A few interesting tid bits this week.

  • CHS  (Community Health System) announced they’re going to buy HMA (Health Management Associates) for $3.6 Billion.  CHS would have a total of 206 hospitals if this deal goes through.


  • Effective 8/1, Oregon Medicaid removed the managed care assignment information from the eligibility response. Members that are assigned to Heath Share in Oregon will need to contact them directly to verify if the member has Kaiser, CareOregon, etc.  From what I can tell, none of the eligibility vendors have HealthShare data yet so it will either be another phone call or you will have to log into their portal.


  • United Health Community Care electronic eligibility responses are returning bad ID numbers for members in Ohio and New Jersey.  UHC is investigating but they aren’t known for their speed. Make sure you double check the ID number against their new cards before you change anything in your registration system.