CMS installed the following changes on 4/6 to their Medicare eligibility transaction.

ESRD Changes

CMS will only provide ESRD information if the service type  RN (Renal) or CQ (Case Management)  are sent in the request. Previously it was returned with service types 14 ( Renal Supplies in the Home or 15 (Alternate Dialysis Method). They will also only be returning the information if the dates of service requested intersect a segment of ESRD coverage. Another change is that CMS will no longer return the dialisys method code or the method start date. They will return the information below when applicable:

1. ESRD Coverage Period Effective Date
2. ESRD Coverage Period End Date (if applicable)
3. ESRD Dialysis Start Date (if applicable)
4. ESRD Dialysis End Date (if applicable)
5. ESRD Transplant Effective Date (if applicable)

New Preventive Service HCPCS Code for Hepatitis B Screening

CMS will now support inquiries for a Hepatitis B Screening when HCPCS  code G0499 is requested. They will return the next eligible date when this code is sent in the request.

Smoking Cessation Response Changes.

In the past, CMS returned either the smoking cessation next eligible date or the number of base and remaining sessions available for a current cessation period. They  also returned  all cessation periods that overlapped  the dates of service in your request. Effective with this release, the HETS 271 response now only  returns the most recent smoking cessation period. They also no longer return the date the beneficiary is next eligible to receive the benefits.

If the Medicare Beneficiary has actual smoking cessation/counseling benefit usage within the previous 12 months (based on the HETS 270/271 system date), HETS will return the following smoking cessation/counseling information:

1. Base smoking cessation/counseling sessions will be returned as ‘8’
2. Remaining smoking cessation/counseling sessions will be returned using an improved calculation process.  
3. The initial cessation session date of the prior smoking cessation/counseling period. No next eligible date will be returned but Medicare Providers can interpret the presence of a smoking cessation initial session date within the last 12 months to determine Medicare Beneficiary eligibility.

If the Medicare Beneficiary has zero smoking cessation/counseling benefit usage within the previous 12 months (based on the HETS 270/271 system date), HETS will return the following smoking cessation/counseling information:

1. Base smoking cessation/counseling sessions will be returned as ‘8’.
2. Remaining smoking cessation/counseling sessions will be returned as ‘8’.
3. No next eligible date will be returned but Medicare Providers can interpret the absence of a smoking cessation initial session date within the last 12 months to determine Medicare Beneficiary eligibility

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 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.

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.

1. CMS will begin returning all diagnosis codes related to each Medicare Secondary payer enrollment period.
2. HCPCs codes for previously rendered  MDPP (Medicare Diabetes Prevention Program) services will be returned in  two circumstances:
   1. The NPI submitted on the eligibility request belongs to a MDPP supplier/vendor
   2. 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.

3. 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).

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.

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)