Optum will be shutting down from May 17th at 5:00 pm to May 19th at 11:59 pm cst. They are moving their internal data center and won’t be accepting any electronic transactions during this time. 837 and 835 files submitted during this time will be held and processed once the data center is functional. Eligibility, claim status, and notification of admission requests will be unavailable until Sunday the 19th. This includes transactions through vendors as well as transactions submitted directly on their portal.
If you aren’t using Optum directly, there’s a high likelihood that your clearinghouse is connecting to them in some way- especially for UHC transactions. If your vendor hasn’t made some type of announcement, it would be wise to reach out to them to see if this will affect them.
Anthem Shutting Down Direct Connections
Anthem will be shutting down access to their direct connections this week. Previously vendors had the option to connect to Anthem directly versus connecting to them via a clearinghouse. Several years ago, Anthem selected Availity to be manage their portal and be their vendor of choice and requested that all vendors move to connectivity through Availity. On May 15th, Anthem will be shutting down any means of connecting to them directly for 27X transactions (eligibility, claim status, etc). I’ve copy their latest announcement below.
Subject: Attention REAL-TIME SUBMITTERS – Immediate Action Required – Reminder
Attention REAL-TIME SUBMITTERS
Immediate Action Required
If you currently submit 270, 276 or 278 transactions directly to Anthem or one of its affiliate companies, it is imperative that you transition to Availity.
If you are using any of the below URLS, and do not migrate by 5/15/2019, you will experience service disruption for your Real-Time transactions.
To avoid a service disruption, you must contact Availity today at 800.282.4548 or visit their website at www.availity.com for additional information./05/06
CMS installed the following changes on 4/6 to their Medicare eligibility transaction.
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:
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:
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:
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.
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 email@example.com.
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.
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.
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:
Claim Status Inquiry (276/277):
We’ll make the following change:
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.
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:
CMS will be making the following changes their eligibility response this month.
• Medicare Beneficiary Demographics
• Date of Death
• Unlawful Occurrences
• Medicare Part B Entitlement
• MDPP Coverage
• MDPP Financial Information
• Medicare Advantage Enrollment(s)
• Medicare as a Secondary Payer (MSP) Enrollment(s)
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.
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.
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.