Upcoming Aetna Eligibility Response Changes 2/8/2019
Aetna will be making the changes below to their eligibility response on February 8th. Pay particular attention to the first one. If your eligibility vendor hasn’t changed their system to stop allowing member ID searches without a DOB, you’ll get a DOB error.
- When we receive an eligibility request with only a member ID and without a date of birth, we’ll return an error code of AAA-58 (Invalid/missing DOB). We’ll apply this change to all member ID-only requests, including Health Rules Payer IDs, Social Security Numbers and Badge IDs. However, this change will not be applicable to HMO ID requests, such as those beginning with ME.
- When a user submits a family search, we’ll return the dependent’s effective and termination dates.
CMS Announces Plan to Discontinue CWF Eligibility
CMS sent out the announcement below on 12/7/2018 regarding the phasing out of the Common Working File for eligibility. It’s taken 6 years but CMS finally feels they have data parity between their X12 eligibility solution and the common working file. The phase out is scheduled to begin in Summer 2019.
In December 2012, CMS announced plans to discontinue the Common Working File (CWF) beneficiary health insurance eligibility transactions (MLN Matters® Special Edition Article SE1249). In that same article, CMS also announced the HIPAA Eligibility Transaction System (HETS) would be the single source for this data. CMS subsequently delayed this effort based on feedback about the differences in data returned between the two systems and the one-year limit to HETS historical search capability. CMS resolved these issues and is moving forward to phase-out the CWF beneficiary health insurance eligibility transactions. This will address inefficiencies of maintaining two different systems returning the same data.
Beginning in the summer of 2019, CMS plans to terminate access to CWF eligibility queries for those who already utilize HETS. If you currently use both CWF and HETS to get Medicare beneficiary health insurance eligibility information, you should immediately begin to use HETS exclusively.
Please submit questions to mcare@cms.hhs.gov.
How many of you are still using the CWF for eligibility? If you’re still using it, I would love to know why in the comments.
Medicare Eligibility Upcoming Release 12/8/2018
CMS has announced several upcoming changes to the Medicare eligibility response. The release is scheduled for 12/8 and the system won’t be available from 7:00 am to 7:00 pm Saturday as they complete this release. I’ve listed a summary of the changes below but the complete release notes can be found here.
- CMS will begin returning all diagnosis codes related to each Medicare Secondary payer enrollment period.
- HCPCs codes for previously rendered MDPP (Medicare Diabetes Prevention Program) services will be returned in two circumstances:
- The NPI submitted on the eligibility request belongs to a MDPP supplier/vendor
- The eligibility request is sent with “Case Management” (CQ) as the service type
CMS may potentially return the following codes based on the beneficiaries previous usage: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9882, G9883, G9884, G9885, G9890 and G9891.
- Medicare Advantage and Medicare Part D responses will begin returning the plan name if the plan benefit package (PBP) number is available. The PBP is the 3 digit code returned after the MCO/Part D contract number (H number).
Aetna Eligibility and Claim Status Changes – August 10th Release
Please see the changes Aetna just announced for their August 10th release.The network identification change will be a great addition.
Eligibility and Benefits Inquiry (270/271):
We’ll make the following changes:
- We’ll make changes to our responses to ensure we specify whether a provider is included or excluded specifically for a plan sponsor’s narrow network regardless of their participation in the overall Aetna network.
- We’ll make a change in our responses to return additional information along with capitated service provider names, giving the service they provide (for example, lab or X-ray).
- We’ll make the following changes when a user submits criteria for an alpha search:
- We’ll use a hierarchy flow (which is the same process we use for an ID number search) when more than one active member ID is found for a member. Using the submitted service type code (STC), we’ll use the following hierarchy order (STC 30 (Health Benefit Plan Coverage) will use medical first): medical, then vision, then dental, then RX to see if the member is covered in any of these benefit groups.
- We’ll uniquely identify the member ID and return the correct coverage when an alpha search is submitted for group STCs 47 (Hospital), 60 (General Benefits) and 35 (Dental Care) or multiple STCs are submitted. In the case of multiple submitted STCs, we’ll use the first STC in the list.
- We’ll make a fix to ensure we return the correct benefits and messaging for participating providers for members with Aexcel Plus and Institutes of Quality (IOQ) plans.
Claim Status Inquiry (276/277):
We’ll make the following change:
- We’ll start to return the Patient Control Number (where applicable) in our responses.
Medicare MBI and Medicare Eligibility Response Changes
CMS sent out the notice below last week in MLN. they have still not decided to allow vendors like Change Healthcare, Availity, or Experian Health to access this tool. If a Medicare beneficiary presents without their new card and they’re in one of the states that has received their cards, you will have to log onto the MACs site to find the new number.
New Medicare Card: MBI Look-up Tool Available through your MAC
All Medicare Administrative Contractor (MAC) secure portal Medicare Beneficiary Identifier (MBI) look-up tools are ready for use. If you don’t already have access, sign up for your MAC’s portal to use the tool.
Submit four data elements about your patient through the tool, and we will return the MBI if we have already mailed the new Medicare card. Medicare is mailing new cards in phases by geographic location. For more information about the MBI, read the MLN Matters® Special Edition Article.
We are currently mailing new cards to people who:
- Live in Alaska, American Samoa, California, Delaware, District of Columbia, Guam, Hawaii, Maryland, Northern Mariana Islands, Oregon, Pennsylvania, Virginia, and West Virginia
- Get Railroad Retirement Board benefits
- Are newly entitled to Medicare
Medicare Eligibility Response Changes June 2018
CMS will be making the following changes their eligibility response this month.
- CMS will start allowing service type code CQ to be requested. CQ (Case Management) should be sent when requesting eligibility information on the Medicare Diabetes Prevention Program.
- Responses for providers that are identified as an MDPP provider will change. If an eligibility response is received for a provider that has a D1 specialty code in their NPI file, the response will only return the following:
• Medicare Beneficiary Demographics
• Date of Death
• Unlawful Occurrences
• Medicare Part B Entitlement
• MDPP Coverage
• MDPP Financial Information
• ESRD
• Medicare Advantage Enrollment(s)
• Medicare as a Secondary Payer (MSP) Enrollment(s)
More Information on the Medicare MBI
I received the email below CMS this morning and started doing some digging. We’ve been testing beneficiaries and found that MBI’s are on file with CMS but the card hasn’t been mailed so the message isn’t showing up in the eligibility response. Depending on the state you’re in, it may be a while before you see any of the new cards or an indication that they’ve had a new card mailed.
New Medicare Card Project – Important Updates
CMS started mailing newly-designed Medicare cards with the new Medicare Beneficiary Identifier (MBI), or Medicare Number. People enrolling in Medicare for the first time will be among the first to get the new cards, no matter where they live. Current Medicare beneficiaries will get their new cards on a rolling basis over the coming months. We will continue to accept the Health Insurance Claim Number (HICN) through the transition period.
During our planning, we continuously adjusted and improved our mailing strategy to make sure we are:
•Mailing the new cards to accurate addresses
•Protecting current Medicare beneficiaries and their personal information in every way possible
We are working on making our processes even better by using the highest levels of fraud protection when we mail new cards to current Medicare beneficiaries. Over the next few weeks, we will complete this additional work and begin mailing new cards to current Medicare beneficiaries.
We are committed to mailing new cards to all Medicare beneficiaries over the next year. For more information, visit the New Medicare Card landing and provider webpages.
Apparently CMS is issuing MBIs for newly eligible Medicare beneficiaries beginning in April. Currently eligible beneficiaries are being mailed on the schedule below.
6 Things You Need To Know About Medicare Eligibility and the MBI
It’s finally here. CMS will start sending out the new cards with the MBI next week so you’ll start seeing those cards soon. I’ve listed a few things I thought was important about this transition. As I hear more information, I’ll pass it along.
1. CMS will be updating their eligibility system on 4/1 to accept the new MBIs. You should be able to start checking eligibility with those IDs once the maintenance window is over at 12:00 pm (noon) on Sunday.
2. ID numbers for Railroad Medicare members will now be in the same format as all other Medicare beneficiaries. You won’t be able to distinguish them by their ID anymore. The response will return a message indicating that the member is a Railroad Retirement beneficiary.
3. You will be able to send either the MBI or the HICN until December 2019.
4. CMS will return the following message if the beneficiary has been issued a new card :
“CMS mailed a Medicare card with a new Medicare Beneficiary Identifier (MBI) to this beneficiary. Medicare providers, please get the new MBI from your patient and save it in your system(s).”
This message will NOT be returned for beneficiaries that are enrolled in a Medicare Advantage plan.
5. CMS will not return the MBI in a response if the HICN is used in the request. If the HICN is sent in the eligiblity request, the HICN will be returned.
6. CMS will be providing an MBI look up tool that will be available in June. Currently this tool will only be available via the MACs provider portals. CMS is not planning to make this tool accessible to eligiblity vendors like Availity and Change Healthcare.
CVS Buying Aetna for $67 Billion
I’m completely fascinated by the thought of a pharmacy chain buying a major payer. I read somewhere that they want to add small walk in clinics to all the stores and steer people there for services like preventive service and other non urgent treatments.
New Medicare Card Images
CMS released images of the new Medicare card along with some details on the new design. The release is still several months away but they’ve started sending out marketing materials already. I really wish some of those materials would include telling them to stop carrying their old card.
Details of the new design:
- Consumer tested by people with Medicare
- Positively reviewed among 10 possible cards designs
- Strong preference to maintain red, white and blue palette
- Easy to read, copy, scan at provider offices
- Smaller size to match the size of a standard credit card
- Bilingual in English/Spanish
- Gender & signature line won’t appear on new Medicare cards
- All cards, including for Puerto Rico, will be printed on white paper
Have you see the “Guard Your Card” commericials?
Medicare Eligibility Response Changes 11/4/2017 Release
CMS will be releasing some changes on November 4th for the HETS eligibility response that are pretty significant. I’ve summarized the items below and included a link to the full document. Numbers 3, 4, and 6 were particularly interesting to me.
CMS 270/271 Release Notes November 4th
1. The following new preventative benefits will be added when requested in the inquiry.
81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
G0297 – Low dose CT scan (LDCT) for lung cancer screening
G0442 – Annual alcohol misuse screening, 15 minutes
G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G0472 – Hepatitis C antibody screening, for individual at high risk and other covered indication-
G0473 – Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes
G0475 – HIV antigen/antibody, combination assay, screening
2. New insurance type codes added for Medicare Secondary payer response
• AP – Auto Insurance Policy – this indicates a No-Fault Medicare Set-Aside Arrangement (NFMSA)
• LT – Litigation – this indicates a Liability Medicare Set-Aside Arrangement (LMSA)
3. An indication of QMB enrollment will be returned for beneficiaries if CMS shows them enrolled during certain periods based on the dates requested.
4. All admissions during a date span will be returned individually. Previously if the beneficiary had multiple admissions during a date span, the response would show the admissions as one admission.
5. Hospice information will only be returned for beneficiaries with Part A entitlement.
6. The response will indicate if the beneficiary isn’t eligible for preventive codes G0402, G0403, G0404, and G0405.
7. Preventive information won’t be returned for beneficiaries that have QMB for the dates requested.
