Industry Updates for December 2019
Happy December everyone. Below are a few things that have crossed my desk recently that I found particularly interesting so I wanted to share. If you’ve run across any interesting articles lately, feel free to share them in the comments.
UHC to Open Medicare Centers in Walgreens
Humana to Layoff 800 employees by the end of 2019
UHC Faces CMS Sanctions on Medicare Advantage Plan
http://www.startribune.com/unitedhealthcare-plan-faces-medicare-sanction/563068872/
Priority Health and Total Healthcare to Merge
Anthem Suing Federal government for $100 Million in ACA payments
North Carolina Suspends 2/1/2020 Managed Medicaid Implementation
CMS To Begin Revoking Access to CWF Eligibility
Good morning and happy November. As 2019 draws to a close, CMS as finally given a date for starting to get of HIQA, HIQH, ELGA and ELGH. They sent out the announcement below on 11/1. It sounds like they’re starting with clearinghouses first and will trickle down to everyone else later. I’ll pass on information on this as it becomes available.
” CMS will begin revoking access to Common Working File (CWF) eligibility transactions HIQA, HIQH, ELGA and ELGH effective February 1, 2020. Submitters that aggregate transactions for otherwise disparate providers (e.g., clearinghouses, billing services, software vendors, etc.) and have both HETS and CWF based eligibility access should use HETS exclusively.
CMS will remove HIQA/HIQH/ELGA/ELGH access for these submitters by revoking role-based access for specific CMS RACF IDs. CMS will revoke access starting with high-volume aggregators. Aggregators that use both HETS and CWF based eligibility should assume they must use HETS only no later than February 1, 2020.”
MBI Transition Period Coming to an End
As we wrap up Q3, I’m seeing an increase in questions about the MBI and using it on Medicare eligibility questions. I suspect this is because the transition period for using the HICN or the MBI is coming to an end. Beginning January 1st, 2020 you will no longer be able to use the HICN for eligibility or claims (with a few exceptions).
One of the complaints I’ve seen is that HETS is returning errors in some cases when eligibility is searched using the MBI that’s on the card. I’ve heard that it’s possible the beneficiary’s MBI may change from the one that was originally issued. I’m validating this with CMS and will get back to you on what I find out. The majority of the problems I’ve seen with the MBI have been user keying errors so please make sure you’re keying exactly what’s on the card. If you still haven’t gotten access to the Medicare MBI lookup tool, I highly suggest that you sign up before the end of the year. If you’ve been using it, please leave me a comment and let me know what your experience has been.
Below is a list of exceptions that CMS has published for still using the HICN. I wasn’t aware of most of these so I thought I would pass them along.
Medicare plan exceptions:
- Appeals – People filing appeals can use either the HICN or the MBI for their appeals and related forms.
- Adjustments – You can use the HICN indefinitely for some systems (Drug Data Processing, Risk Adjustment Processing, and Encounter Data) and for all records, not just adjustments.
- Reports – We’re using the HICN on these reports until further notice:
- Incoming to us (quality reporting, Disproportionate Share Hospital data requests, etc.).
- Outgoing from us (Provider Statistical & Reimbursement Report, Accountable Care Organization reports, etc.).
- Reports – We’re using the HICN on these reports until further notice:
- Retrospective reporting – Plans can use the HICN when submitting data for older contract years for applicable systems (e.g., Health Plan Management System).
Fee-for-Service claim exceptions:
- Appeals – You can use either the HICN or the MBI for claims, appeals and related forms.
- Audits – You can use either the HICN or the MBI for audit purposes.
- Claim status query – You can use either the HICN or the MBI to check the status of a claim (276 transactions) if the earliest date of service on the claim is before January 1, 2020. If you’re checking the status of a claim with a date of service on or after January 1, 2020, you have to use the MBI.
- Span-date claims – You can use the HICN for 11X-Inpatient Hospital, 32X-Home Health (home health claims & Request for Anticipated Payments (RAPs)), and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (12/31/2019). You can submit claims received between April 1, 2018 and December 31, 2019 using either the HICN or the MBI. If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019.
- Incoming premium payments – People with Medicare who don’t get SSA or RRB benefits and submit premium payments should use the MBI on incoming premium remittances. But, we’ll accept the HICN on incoming premium remittances after the transition period. (Part A premiums, Part B premiums, Part D income related monthly adjustment amounts, etc.)
- We’re monitoring the use of HICNs and MBIs to see how many of you are using MBIs. We’re also actively monitoring the transition to MBIs to be sure Medicare operations aren’t interrupted.
Aetna Precert and Admission Notification Rejections
This morning Aetna sent out the announcement below regarding some issues they’re having with their EDI transactions for precert and notifications. If you get a rejection with one of the codes listed below, please call the precert number on the members ID card to complete your precert request.
Purpose:
We’d like to let you know we’re rejecting some Precertification Add and Notification transactions, but we’re not returning all the rejection reasons.
Overview:
We’re currently rejecting some Precertification Add and Notification transactions, but we’re not returning all the rejection reasons. Certain transactions are rejecting with the following two codes:
- A3: Not Certified
- 25: Services were not considered due to other errors in the request.
Our systems aren’t returning additional rejection reasons, so we’re unable to determine the exact reason for the rejected transactions. For some rejected transactions, we’ve determined there are duplicate requests.
This issue:
- Is affecting requests initiated on all vendor partner websites
- Isn’t limited to certain plan types
- Isn’t affecting all Precertification Add and Notification transaction requests
We’re researching this issue at a high priority, but we don’t have a resolution date yet. We’ll send an update once we have additional information.
Current Medicare HETS Eligibility Issues
Below is a list of outstanding issues that CMS is on working for the HETS eligibility response. If you’re using eligibility from a vendor (Experian, Change Healthcare, Availity, etc) this is the response you’re receiving. This is also the connection everyone will be required to use once CMS sunsets the CWF eligibility functions.
| Table 1. Open HETS Data Issues Current Data Issues | Percentage of Impacted Medicare Beneficiaries | Date that a Fix is Planned | Detailed Description of the Issue |
|---|---|---|---|
| HETS may be returning incorrect Hospice episode information or occurrence counts when the Medicare Beneficiary has a new Notice of Election (NOE) and had billed Hospice episodes four or more years ago. | 1% | October 2019 | HETS’ data source for Hospice information is the Common Working File (CWF). CMS has identified an issue where CWF is sending an incorrect Hospice information to other systems (including HETS) when the Medicare Beneficiary has a new Notice of Election (NOE) and previously billed hospice periods. CWF updates the file and corrects the Hospice history once a Hospice claim is processed for the new billing period. CWF will update their database and processes to resolve these discrepancies and prevent future occurrences. |
| After the Medicare Beneficiary received the first Pneumococcal Vaccine (PPV), CWF is not sending the eligibility information for the second PPV vaccine to HETS. | 33% | Q1 2020 | HETS’ data source for prior PPV usage is the Common Working File (CWF). HETS returns PPV vaccination data using CWF records for HCPCS 90670 and 90732. HETS correctly returns the PPV vaccination next eligible dates for both HCPCS if the Medicare Beneficiary has never been vaccinated. When the HETS 271 returns no next eligible date available for PPV, the Medicare Beneficiary may have actually only received one of the PPV vaccines and may still be eligible for the second vaccine after a year between deliveries. CMS encourages Providers to discuss the Pneumococcal vaccine and any previous receipt of that vaccine with your patients. |
| CMS has identified a more accurate source of data for End Stage Renal Disease (ESRD) Dialysis Start Date and ESRD Dialysis End Date. | 1% | August 2019 | HETS currently returns ESRD information on the 271 response when Service Type Code ‘CQ’ or ‘RN’ are included in the 270 request. CMS has identified an issue with the data source used for the End Stage Renal Disease (ESRD) Dialysis Start Date and ESRD Dialysis End Date. CMS is working to correct this issue quickly. In the interim, CMS encourages dialysis clinics to co-ordinate with each other to get correct Dialysis Start Dates for the coordination of the Medicare Beneficiary’s dialysis training. CMS will modify its data source to utilize the improved data. The format of the ESRD data in the 271 response will be exactly the same as is currently in use. |
Increase in Aetna COB Claim Issues
Aetna sent out the message below last week so I thought I would pass it on.
Date:
June 28, 2019
Purpose:
We’d like to let you know that incomplete and erroneous electronic Coordination of Benefits (COB) claims submissions are resulting in processing and payment delays.
Overview:
Incomplete and erroneous COB submissions have significantly affected our claims auto-adjudication process and has resulted in delayed payments while waiting for additional information from a billing provider or billing vendor.
We’ve noticed an increase in the number of electronic claims submitted with a “Y” response in the COB indicator field.
- A “Y” response in the COB indicator field should be
entered only if other coverage exists.
- All subsequent COB data fields must be populated as well, including the name of the other carrier, the name of the subscriber’s employer, and the corresponding policy number.
- If the patient does not have other coverage, an “N”
must be populated in the COB indicator field.
- All subsequent COB data fields should be left blank. Random characters or symbols must not be populated in these fields.
Required action:
- Please review your systems to ensure the COB indicator field isn’t pre-populated with a “Y” response. If so, please remove the automatic designation. The appropriate response for each new claim submission must be entered as outlined in the information above.
Upcoming Optum Shutdown and Anthem Migration Request
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.
Click here to see the full announcement.
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 Eligibility Response Changes Effective 4/6/2019
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:
- ESRD Coverage Period Effective Date
- ESRD Coverage Period End Date (if applicable)
- ESRD Dialysis Start Date (if applicable)
- ESRD Dialysis End Date (if applicable)
- 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:
- Base smoking cessation/counseling sessions will be returned as ‘8’
- Remaining smoking cessation/counseling sessions will be returned using an improved calculation process.
- 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:
- Base smoking cessation/counseling sessions will be returned as ‘8’.
- Remaining smoking cessation/counseling sessions will be returned as ‘8’.
- 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
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.