CMS Responds to PAID Act with Technical Alert and Updated NGHP User Guide

CMS, Mandatory Insurer Reporting, Medicare Set-Aside Blog on June 14, 2021
Posted by Shannon Flynn

by Frank Fairchok, Vice President of Medicare Reporting Services

On December 11, 2020 the Provide Accurate Information Directly Act, or PAID Act, was signed into law requiring CMS to modify the Mandatory Insurer Reporting query process to provide three years of Medicare Part C and Part D history for claimants identified as beneficiaries. The intent of this law is to give Responsible Reporting Entities (RREs) visibility to Medicare Advantage (Part C) and Medicare Prescription Drug (Part D) plans where a beneficiary is currently enrolled or has been enrolled in the last three years. These plans have similar rights of recovery as Medicare Parts A & B, when a Non-Group Health Plan is the primary payer. However, RREs have been working to meet this requirement without a reliable way to identify Part C and Part D plans. The PAID Act gives CMS a mandate to resolve that issue by December 11, 2021. CMS responded to the mandate this week with the following publications and updates:

Technical Alert
The Technical Alert provides background information on the passage of the PAID Act and describes how CMS is planning to implement the new requirements. The alert states that effective December 11, 2021, the query response will include the following fields for Parts C and D plans (for up to 12 instances for each plan):

  • Plan Contract Number
  • Plan Enrollment Date
  • Plan Termination Date
  • Plan Contract Name
  • Plan Benefit Package Number
  • Plan Street Address, City, State and Zip

In addition, the alert states that CMS will also provide the most recent Part A and Part B entitlement dates. While not mandated by the PAID Act, this information will certainly be useful as RREs will now have visibility into Medicare enrollment and insight regarding how the dates interact with the claim details.

CMS also indicates that they will be supporting a testing period beginning September 13, 2021 to allow RREs to prepare for the changes to the file structure and process. In tandem with these changes, CMS will be providing updated HIPAA Eligibility Wrapper (HEW) software that translates flat text files into HIPAA compliant ANSI X12 270/271 transaction sets.

User Guide 6.4
The update to version 6.4 of the NGHP User Guide contains many changes that support the PAID Act as described in the section above. In addition to these modifications, other notable changes include:

ORM Termination
CMS has amended policy around ORM Termination with the addition of new criteria allowing an RRE to terminate ongoing responsibility for medicals on a claim. As stated in Section 6.3.2 of Chapter III Policy Guidance:

“Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

  • No claims were paid with any diagnosis codes related to alleged ingestion, implantation, or exposure; and
  • No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
  • Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
  • The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.”

Event Table
CMS has added an event to Event Table 6-12 in Chapter IV – Technical Information. This event describes the treatment of reporting where a TPOC ends ORM on only a portion of the claim and therefore ORM continues for some ICD codes. CMS details how to update the ORM related codes on the original claim submission while also adding another claim report for the TPOC and resolved ICD codes as seen here:

(Click image for larger version)

Error Code SP55
CMS has added error code SP55 to the error code table and describes the cause of this error:

“MSP Effective Date is less than the earliest beneficiary Part A or Part B Entitlement Date. MSP can only occur after the beneficiary becomes entitled to Medicare Part A or Medicare Part B. An MSP Effective Date that is an invalid date will also cause an SP55 error. No correction necessary – resubmit records with this error on your next file submission.”

It is interesting to note that this new error code appears to function similarly to error code SP31, which was removed from the User Guide in version 6.3 in April of this year.

In complying with the requirements of the PAID Act, CMS has initiated substantial changes to the query process to which the industry will need to adapt. The current text string for the query response record is 300 characters.  However, on December 11, 2021 that will change to 5,608 characters, a substantial amount of new and useful data. With six months to prepare for production changes, it is important to prioritize the necessary modifications, or an RRE might end up in a situation where they cannot identify beneficiaries at all using the 270/271 exchange.   

CMS is hosting a webinar on June 23 at 1:00 pm ET to further discuss these changes and provide an opportunity for webinar participants to ask questions.

Uncertain about the impact these changes may have on your organization’s Mandatory Insurer Reporting (MIR) compliance? MEDVAL works with our clients to simplify the MIR reporting process and achieve compliance, while helping companies avoid potentially stiff penalties. If you have questions regarding the Mandatory Insurer Reporting process or the PAID Act, please contact us at [email protected].