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 2019HETS’ 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 2019HETS 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:

  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