Medicare Eligibility System Migration

CMS is in the process of migrating submitters from their HETS legacy eligibility system to their new “Redesign” system. Providers and clearinghouses are being moved to this new system in groups and the first group is moved last week. The HETS system is primarily accessed by clearinghouses but I think there are some health systems that are accessing it directly.

There are a few things to be aware of regarding this migration:

1. CMS is requesting that each submitter, re-enroll all of the NPIs in CMS new provider ID database. This is a simple process of sending a file and having each NPI attached to a submitter ID but it has to be completed a couple of weeks before the actual migration.
2. CMS is requiring that each vendor deactivate any NPIs that are no longer active with the submitter. Rumor has it they’re going to deactivate any NPIs that haven’t sent a transaction in the past 6 months.
3. Moving to the new system is bringing a few changes to the way CMS will respond to certain requests. Many of these situations will need to be handled by your eligibility vendor but there are some that users can impact directly:
   • Sending an inactive CPT in your request for Medicare preventive benefits will result in an error. Example sending code 90669 for dates of service after 1/1/2016 will cause an error.
   • Sending the middle name or middle initial will result in an error. I’m not sure how this will work in situations where SSA has the first name and middle initial in the first name field.
   • Sending the beneficiaries gender will result in an error.

If you would like to read the full release summary with all the changes, click the link below:

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/R2016Q300HETS270271ReleaseSummary.pdf

Also see the new full HETS companion guide if you’re interested in the business logic they use for responses.

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/HETS270271CompanionGuideUpcoming.pdf

I’m hoping that this system migration will be uneventful and straightforward but you can never tell with CMS. This move gets them closer to being able to truly sunset the common working file eligibility queries, which is long overdue. I won’t be surprised if CMS sends out an announcement Q1 2017 regarding shutting off the CWF queries.