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:

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