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.).
• 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.

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.

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.

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.

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.

• https://www.edirealtime.com/edirealtimeph2/edirealtime

• https://www.hipaaiaswebservice.com/wsedirealtime/wsedirealtime

• https://www.hipaaediwebservice.com/wsedirealtime/wsedirealtime

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