Transmittal 198 Date: DECEMBER 9, SUBJECT: Termination of the Existing Eligibility-File Based Crossover Process at All Medicare Contractors

Transcription

1 anual ystem Depatment of ealth & uman evices (D) entes fo edicae & Pub One-Time Notification edicaid evices () Tansmittal 198 Date: DEEBE 9, 2005 hange equest 4231 UBJET: Temination of the Existing Eligibility-ile Based ossove Pocess at All edicae ontactos. UAY O ANGE: Though this change equest, the is poviding instuction to the edicae contactos concening thei esponsibilities as they elate to the discontinuance of the cuent eligibility file-based cossove pocess effective with Januay 3, NEW/EVED ATEAL EETVE DATE: Januay 9, 2006 PLEENTATON DATE: Januay 9, 2006 Disclaime fo manual changes only: The evision date and tansmittal numbe apply only to ed italicized mateial. Any othe mateial was peviously published and emains unchanged. oweve, if this evision contains a table of contents, you will eceive the new/evised infomation only, and not the entie table of contents.. ANGE N ANUAL NTUTON: (N/A if manual is not updated) = EVED, N = NEW, D = DELETED Only One Pe ow. /N/D N/A hapte / ection / ubection / Title. UNDNG: No additional funding will be povided by ; ontacto activities ae to be caied out within thei Y 2006 opeating budgets. V. ATTAENT: One-Time Notification Attachment *Unless othewise specified, the effective date is the date of sevice.

2 Attachment One-Time Notification Pub Tansmittal: 198 Date: Decembe 9, 2005 hange equest 4231 UBJET: Temination of the Eligibility ile-based ossove Pocess At All edicae ontactos. GENEAL NOATON A. Backgound: ince July 2004, the entes fo edicae & edicaid evices () has been testing its national oodination of Benefits Ageement (OBA) consolidated cossove pocess with well ove 120 tading patnes. Duing this time, the and the oodination of Benefits ontacto (OB) have bought the ealth nsuance Potability and Accountability Act (PAA) Ameican National tandads nstitute (AN) X12-N 837 oodination of Benefits (OB) claim files into high degees of compliancy with the vesion 4010-A1 837 nstitutional and Pofessional laim mplementation Guides. onsequently, since June 2005, has been moving tading patnes into cossove poduction with the OB, and that tend has ecently been acceleating. The ecently issued joint signatue memoandum (J) to povide guidance to all edicae contactos egading the discontinuance of the existing eligibility file-based cossove pocess effective Decembe 31, Though this communication, the also descibed a waive pocess that tading patnes that will not be moving into OBA cossove poduction by Decembe 31, 2005, must follow. is issuing this instuction to claify all edicae contacto equiements as they elate to the discontinuance of the existing eligibility file-based cossove pocess. Also, though this instuction, is updating the end date fo the existing edicae eligibility file-based cossove pocess to Januay 3, 2006, fo edicae contacto puposes. This enables the contactos to initiate the temination pocess fo those tading patnes that have not moved to OBA poduction on Decembe 31, B. Policy: has decided that it will no longe coss claims ove to tading patnes pusuant to signed cossove ageements and the submission of OB eligibility files beyond Januay 3, As of that date, the OB will exclusively coss ove all claims to tading patnes in the PAA AN X12-N 837 OB (vesion 4010-A1) fomats via the OBA eligibility file-based cossove pocess, unless 1) edicae contactos have submitted waive equests to on behalf of thei cuent tading patnes no late than Decembe 16, 2005 (note: Tading patnes would need to have submitted these equests to the edicae contactos no late than Decembe 7, 2005), and 2) the has appoved the tading patnes waive equests in advance of Januay 3, (Note: plans to each a decision on all waive equests no late than Decembe 21, 2005, unless late waive equests must be addessed.) The has developed a standad OBA Tading Patne Poduction Waive equest fom (see Attachment A) that edicae contactos shall submit to tading patnes when they contact them to equest a waive. The Waive equest must be completed in its entiety and must document all edicae contactos with whom the tading patne has executed cossove ageements. f a tading patne has executed cossove ageements with multiple edicae contactos, the tading patne need only submit a single waive equest to one (1) of its associated edicae contactos by Decembe 7, ealthcae cleainghouses will be equied to submit one (1) waive equest pe client to at least one (1) of thei affiliated edicae contactos. As pat of its eview of a tading patne s waive equest, will take

3 the esponsibility fo notifying all othe affected edicae contactos of the tading patne s equested waive and estimated OBA poduction date. Tading patnes should be eminded that, as confimed in the attached Waive equest fom, thei estimated poduction date cannot exceed ach 31, As afoementioned, all edicae contactos shall submit OBA Tading Patne Poduction Waive equest foms to no late than Decembe 16, Once a edicae contacto eceives a Waive equest, it shall veify that the fom was completed in its entiety. f the edicae contacto detemines that the fom was incomplete, it shall etun the fom to the sende, specifying that the tading patne needs to complete all potions of the document (ection.a though J). f complete Waive equests ae eceived electonically via , they should be fowaded to at OBAPocess@cms.hhs.gov. f, by contast, complete Waive equests ae eceived fom tading patnes via fax o mail, the foms may be faxed to to the attention of usan Oken at (410) The will appove o deny all waive equests eceived by Decembe 16, 2005, no late than Decembe 21, Waive equests that contain no justification o inadequate justification will be ejected. esponses will be sent to the edicae contacto that submitted the waive equest. n addition, will espond to all edicae contactos listed in ection. J of the OBA Tading Patne Poduction Waive equest and will copy the designated tading patne contact. Temination Pocess Notifications to Tading Patnes That ave Not equested a Waive All edicae contactos shall begin the temination of the existing eligibility file-based cossove pocess with each individual tading patne that has not equested and eceived a waive no soone than Januay 3, That temination pocess shall include sending an individual tading patne notification that a waive equest was not eceived. onsequently, the edicae contacto will immediately begin actions necessay to cease cossing eligibility file-based claims to the tading patne. Actions necessay to end the cossove pocess with a tading patne may include, but ae not limited to, teminating the existing cossove Tading Patne Ageement; cleaing esidual claims fom the payment floo; and submitting final invoices to the tading patne. ontactos shall ensue that the tading patne temination pocess notification includes a segment wheein the contacto specifies a final date by which these actions will be accomplished. ontactos shall submit a copy of thei temination pocess notification to at OBAPocess@cms.hhs.gov on the same date that the notice is tansmitted to the individual tading patne. This will enable to complete a side-by-side compaison, theeby ensuing that all tading patnes that will not move into OBA poduction by Decembe 31, 2005, will eithe have submitted a waive o been tageted by edicae contactos to eceive a temination notification. n lieu of notifying and the tading patne on the same date, the edicae contacto may contact pio to sending the temination pocess notification afte Januay 3, 2006., in tun, will discuss each temination pocess notification with the associated edicae contactos pio to the final date that actions will be accomplished by those edicae contactos to end the eligibility file-based cossove pocess with an individual tading patne. mpact on andatoy edigap ( laim-based ) ossoves The Januay 3, 2006, end date does not apply to mandatoy edigap ( claim-based ) cossoves, which ae authoized by 4081(a)(B) of the Omnibus Budget econciliation Act of 1987 [Public Law ], and cuently suppoted by Pat B and Duable edical Equipment egional aie (DE)

4 contactos. Pat B and DE contactos shall continue to send such cossoves to edigap insues eithe via pape o electonic eceipt, including the 837 Pofessional OB claim vesion 4010-A1 fomat, until futhe notice fom is povided subject to equiement # in hange equest The final ealth nsuance Potability and Accountability Act (PAA) tansaction and code set egulations stipulate that tading patnes should be able to accept PAA Ameican National tandads nstitute (AN) X12-N 837 claims (vesion 4010-A1) fom othe payes. Theefoe, Pat B and DE contactos should ensue that new tading patnes that equest mandatoy edigap (claim-based) cossove claims, outside of a fomal cossove ageement, will eceive these claims in the appopiate PAA AN X12-N 837 Pofessional OB (vesion 4010-A1) fomats. (NOTE: This pactice does not violate the equiements povided in Tansmittal 448, change equest 3658, which applied to new eligibility file-based cossove ageements.). BUNE EQUEENT hall" denotes a mandatoy equiement "hould" denotes an optional equiement equiement Numbe equiements ontactos shall discontinue thei eligibility file-based cossove pocesses with tading patnes effective Januay 3, 2006, unless they have eceived a waive equest fom such entities and unless has appoved the waive equest by Decembe 21, 2005 (o by Decembe 30, 2005, fo late waive equests). esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W (NOTE: OBA Poduction Waive equests shall be diected to OBAPocess@cms.hhs.gov and shall include Waive equest in the subject line.) ontactos shall post Attachments A and B on thei websites in the appopiate section (e.g., cossove segment) fo claims cossove tading patnes to view.

5 equiement Numbe equiements ontactos that eceive waive equests beyond the tading patnes deadline to such equests shall send a high pioity alet, including the completed waive foms, to at OBAPocess@cms.hhs.gov, including Waive equest in the subject line. will then contact the edicae contactos intenal cossove staff to discuss next steps ontactos that eceive equests fom tading patnes fo waives shall immediately send each entity a copy of standad OBA Tading Patne Poduction Waive equest fom (see Attachment A) to be completed in its entiety along with the suggested language (see Attachment B) ontactos shall infom each healthcae cleainghouse that seeks a waive on behalf of its clients that it shall be equied to submit one (1) waive equest fo each insue client to at least one (1) of its affiliated edicae contactos f does not appove a waive equest fo a cleainghouse client, the contacto shall infom the healthcae cleainghouse to emove the client fom its eligibility file no ealie than Januay 3, 2006, and no late than detemined by the edicae contacto to accomplish the actions necessay to end the eligibility filebased cossove pocess with the individual client. (ee equiement #7.2 below fo moe infomation egading the temination pocess notification pocedue.) ontactos shall offe to eceive completed Waive equest foms fom tading patnes via electonic o via facsimile (fax) o by mail only if the two foegoing eceipt options ae not available. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W

6 equiement Numbe equiements Each contacto shall include its contact infomation in its cove lette to tading patnes egading the discontinuance of eligibility-file based cossove (see Attachment B) and shall accompany the distibution of the Waive equest fom Upon eceipt of a OBA Tading Patne Poduction Waive equest fom, the contacto shall veify that the tading patne completed pages 1 and 2 of the fom (ection.a-j) in thei entiety f the contacto detemines that the Waive equest fom was not fully completed, it shall etun the fom to the tading patne within two (2) business days of eceipt, with instuctions to complete any missing elements and a eminde of the due date ontactos shall etun incomplete foms in the most expeditious manne possible (e.g., o fax), with a equest fo confimation of eceipt fom the tading patne. This will ensue that tading patnes will be able to meet thei deadline fo waive submissions ontactos that eceive fully completed Waive equest foms fom tading patnes via electonic by thei deadline fo submitting such equests shall complete ection and submit these foms to at OBAPocess@cms.hhs.gov, including Waive equest in the subject line, no late than Decembe 16, ontactos that eceive fully completed Waive equest foms fom tading patnes via fax by thei deadline fo submitting such equests shall complete ection completed and submit them via fax to the attention of usan Oken at (410) This action shall occu no late than Decembe 16, esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W

7 equiement Numbe equiements All edicae contactos shall begin the temination of the existing eligibility file-based cossove pocess with each individual tading patne that has not equested and eceived a waive no soone than Januay 3, To initiate this temination pocess, contactos shall send an individual tading patne notification to any existing tading patne that has not as yet submitted a completed OBA Tading Patne Poduction Waive equest fom. onsequently, the edicae contactos will immediately begin actions necessay to cease cossing eligibility file-based claims to the tading patne Actions necessay to end the cossove pocess with a tading patne may include, but ae not limited to, teminating the existing cossove Tading Patne Ageement; cleaing esidual claims fom the payment floo; and submitting final invoices to the tading patne. (NOTE: Tading patnes will be expected to take the same actions in tems of ceasing tansmission of eligibility files and accepting and paying fo esidual contacto claims unde this scenaio as they would when they move into OBA poduction with the OB.) ontactos shall ensue that the tading patne temination pocess notification includes a segment wheein each contacto specifies a final date by which the temination actions will be accomplished ontactos shall submit a copy of thei temination pocess notification to at OBAPocess@cms.hhs.gov (including Temination Notification in the subject line) on the same date that the notice is tansmitted to the individual tading patne. This will enable to complete a side-by-side compaison, esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W

8 equiement Numbe equiements theeby ensuing that all tading patnes that will not move into OBA poduction by Decembe 31, 2005, will eithe have submitted a waive o been tageted by edicae contactos to eceive a temination notification. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W n lieu of notifying and the tading patne on the same date, in association with equiement 7.4 above, the edicae contacto may contact the pio to sending the temination pocess notification. (NOTE:, in tun, will discuss each temination pocess notification with the associated edicae contactos pio to the final date that contacto actions will be accomplished to end the eligibility file-based cossove pocess fo an individual tading patne.) o puposes of contacting fo equiement 7.5, the contacto shall call a membe of the OBA team (Donna Kettish, ; Bian Pabst, ; Bian Johnson, ; usan Oken, ) and send an to OBAPocess@cms.hhs.gov Pat B and DE contactos shall continue to send mandatoy edigap ( claim-based ) cossoves to edigap insues eithe via pape o electonic eceipt, including the 837 Pofessional OB claim (vesion 4010-A1) fomat, until futhe notice fom is povided The final ealth nsuance Potability and Accountability Act (PAA) tansaction and code set egulations stipulate that tading patnes should be able to accept PAA Ameican National tandads nstitute (AN) X12-N 837 claims (vesion 4010-A1) fom X X X X

9 equiement Numbe equiements othe payes. Theefoe, Pat B and DE contactos should ensue that new tading patnes that equest mandatoy edigap (claim-based) cossove claims, outside of a fomal cossove ageement, will eceive these claims in the appopiate PAA AN X12-N 837 Pofessional OB (vesion 4010-A1) fomats. (NOTE: This pactice does not violate the equiements povided in Tansmittal 448, change equest 3658, which applied to new eligibility file-based cossove ageements.) esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W Until futhe notice, Pat B and DE contactos shall cease the sending of mandatoy edigap cossoves only if: X X 1) They eceive a Beneficiay Othe nsuance (BO) eply taile (29) that includes a edigap OBA D and indicates that the tading patne is in poduction mode with the OB pe equiement # in hange equest 3273; o 2) They eceive a equest fom a edigap insue to discontinue all Othe aie Name and Addess (ONA) o N-key identification numbes (Ds), which ae assigned fo mandatoy edigap (claim-based) cossove puposes. (NOTE: This latte exception would only be applicable if the edigap insue went into OBA poduction with the OB and would intend to identify its coveed membes via an eligibility file, pe its temination notice.) As stated in equiement 1.2 above, contactos that eceive completed foms beyond the tading patnes deadline fo submitting waive equests shall send a high pioity alet

10 equiement Numbe equiements to including Waive equest in the subject line. will contact the edicae contactos to discuss the late eceipt of waive equests. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W. POVDE EDUATON equiement Numbe equiements A povide education aticle elated to this instuction will be available at shotly afte the is eleased. You will eceive notification of the aticle elease via the established "medlean mattes" listsev. ontactos shall post this aticle, o a diect link to this aticle, on thei Web site and include infomation about it in a listsev message within 1 week of the availability of the povide education aticle. n addition, the povide education aticle shall be included in you next egulaly scheduled bulletin and incopoated into any educational events on this topic. ontactos ae fee to supplement edlean attes aticles with localized infomation that would benefit thei povide community in billing and administeing the edicae pogam coectly. esponsibility ( X indicates the columns that apply) haed ystem aintaines Othe a i e D E V W V. UPPOTNG NOATON AND POBLE DEGN ONDEATON

11 A. Othe nstuctions: N/A X-ef equiement # nstuctions B. Design onsideations: N/A X-ef equiement # ecommendation fo edicae ystem equiements. ntefaces: N/A D. ontacto inancial epoting /Wokload mpact: N/A E. Dependencies: N/A. Testing onsideations: N/A V. EDULE, ONTAT, AND UNDNG Effective Date*: Januay 9, 2006 mplementation Date: Januay 9, 2006 Pe-mplementation ontact(s): Bian Pabst (bian.pabst@cms.hhs.gov; ) o usan Oken (susan.oken@cms.hhs.gov; ) No additional funding will be povided by ; contacto activities ae to be caied out within thei Y 2006 opeating budgets. Post-mplementation ontact(s): Bian Pabst (bian.pabst@cms.hhs.gov; ) o usan Oken (susan.oken@cms.hhs.gov; ) *Unless othewise specified, the effective date is the date of sevice. Attachments A and B

12 Attachment A OBA Tading Patne Poduction Waive equest ection. To be completed by Tading Patne A. Name of Tading Patne B. Tading Patne ontact nfomation: Name Phone Numbe All OBA Ds oveed by this equest D. Date of equest E. OBA Testing (Teleconfeence) Goup Numbe. Date of ist Eligibility Testing with the oodination of Benefits ontacto (OB) G. Date of ist laims Testing with the OB. Justification fo Waive equest. Date Expected/cheduled to go into OBA Poduction with the OB Note: (l) All Waive equests must be submitted to an associated edicae contacto to be sent to fo appoval by Decembe 7, (2) All Tading Patnes must be in poduction by ach 31, Thee will not be any waives ganted fo poduction dates late than ach 31, 2006.

13 J. (andatoy) List the names of all edicae ontactos fo which you cuently have Tading Patne Ageements (TPAs). Beside the name of each edicae contacto, specify line of business, i.e., Pat A, Pat B, DE. Next to each edicae contacto in the No. field, list eithe you edicae-assigned nsue D Numbes (numbe that is on the E00 ecod on you eligibility file) o Tading Patne Ageement Numbe(s) ** Please check hee if you do not have othe TPAs with edicae contactos beyond the one to whom you diected you initial Waive equest. Othewise, complete all fields below. Name No. Name No. Note: leainghouses submitting Waive equests on behalf of thei clients must submit a sepaate equest fo each client.

14

15 ection. To be completed by edicae ontacto What fomat is cuently used to coss claims fo this Tading Patne? Ae all lines of business included unde one Tading Patne Ageement? pecial Note: Volume of claims to be cossed weekly Othe omments: ection. Appoval: Yes No Name Title Date omment(s)

16 Attachment B uggested Language o Lette To Tading Patnes The entes fo edicae & edicaid evices () has decided that it will not continue to maintain the cuent eligibility file-based cossove pocess at all edicae contactos concuently with the consolidated OBA pocess at the OB. Theefoe, edicae contactos may no longe coss claims ove to tading patnes pusuant to signed cossove ageements and the submission of eligibility files, beyond Decembe 31, As of that date, the OB will exclusively coss ove all claims to tading patnes in the PAA AN X12-N 837 (vesion 4010-A1) OB fomats via the eligibility file-based OBA pocess, unless edicae contactos equest specific waives on behalf of cuent tading patnes. Waives will be ganted on a case-bycase basis and must include a justification fo not testing the OBA pocess with the OB o why poduction with the OBA pocess is not possible by Decembe 31, f you have adequate justification fo not being in poduction with the OBA consolidated cossove pocess by Decembe 31, 2005, a Waive equest must be submitted to edicae contactos so that they ae eceived no late than Decembe 7, equests can be submitted eithe electonically to o by fax at - - o by mail to. f you have Tading Patne Ageements (TPAs) with multiple edicae ontactos, you only need to complete the attached fom fo one of the contactos, but ection. J. of the Waive equest must include all othe edicae contactos fo which you have TPAs, including Pat A, Pat B, and DE TPAs with the same contacto. The Decembe 31, 2005, end date does not apply to mandated edigap (claim-based) cossove pocesses maintained by Pat B and DE contactos. This pocess will continue at the Pat B and DE contactos until futhe notice. Please be cetain that you etun all thee pages of the attached fom. Attachment