Welcome to eSolutions’ Quarterly CMS Update!
CMS changes existing rules and introduces new ones so frequently that it’s hard to keep up! Now you don’t have to – let eSolutions, your Medicare experts, do it for you. You can count on us to inform you of CMS news, changes and new rules on a quarterly basis by subscribing to our blog.
CMS Q2 2019 Update
WPS EDI Gateway Will Be Discontinued July 1
On July 1, 2019, WPS will shut down the ability to transmit Medicare claims through the WPS EDI gateway. For those impacted providers, we recommend transitioning to the new WPS Community Manager as soon as possible, to avoid disrupting your organization’s ability to submit claims to Medicare. To help address any immediate questions or concerns, please feel free to review our very informative FAQ.
To transition to the WPS Community Manager, please click HERE. You will need your organization’s Trading Partner ID, Primary Contact Name, and Primary Contact Email. Once you obtain your WPS Community Manager credentials, please update your new credentials and submitter ID in File Transfer Service.
If you have any questions, please contact eSolutions’ Client Services at 866.633.4726 or firstname.lastname@example.org.
CMS Set to Begin Delivering ADRs Electronically
If you’re a provider who bills Medicare Administrative Contractors (MACs) for services you provide Medicare beneficiaries, you can sign up next month to get your ADR request letters electronically.
CMS is adding the functionality to send ADR letters electronically, beginning in January 2020. Register with CMS in July to begin receiving an electronic version of ADR letters, known as Electronic Medical Documentation request (eMDR), via the Electronic Submission of Medical Documentation (esMD) system.
Because eMDRs may contain Protected Health Information (PHI), CMS will require a valid consent from the provider or the authorized individual representing the provider, along with destination details, including any delegation to their associated or representing organizations such as Health Information Handlers (HIHs).
Receiving ADRs electronically will be faster and more efficient, and providers can pick any HIH to get their ADRs electronically. In July, providers can register to give their consent for an HIH of their choice to receive transactions on their behalf. Then their ADR letters will be sent electronically as eMDRs. Beginning in January, providers can receive eMDRs (pre- or post-pay) through their HIH and process the data systematically. In April 2020, providers can receive the list of “Requested Documents for an ADR” along with eMDRs through their HIH.
eSolutions is a certified HIH. Before designating us as your HIH, however, providers must register with the CMS National Plan and Provider Enumeration System (NPPES) directly. Then you can go into select eSolutions product and register to receive eMDRs through NexusMD or Maven.
Why should providers sign up to receive eMDRs?
- ADR letter data in an electronic format (eMDR) provides structured data that can be used for system processing
- Electronic ADR letter (as eMDR) reaches the provider faster and makes the exchange traceable
- ADRs received electronically enables efficient management of ADR requests and responses.
MACs Must Mask SSNs
Effective July 1, 2019, Medicare Administrative Contractors (MACs) must mask the Health Insurance Claim Number (HICN) on Standard Paper Remits (SPRs) so that individuals’ Social Security Numbers (SSNs) do not show. Billing staffs should be informed of this change.
CMS Change Request (CR) 11112 instructs MACs to update their systems to ensure that SPRs mailed after July 1 mask the Health Insurance Claim Number (HICN), so the SSN won’t show. Make sure your billing staff is aware of these instructions.
CR 11112 instructs MACs to update their systems, effective July 1, to mask the HICNs and the Railroad Retirement Board HICNs on any print file used to create an SPR for mailing. The Medicare Beneficiary Identifier (MBI) will not be masked.
CMS Creates New CWF Edit for CCNs
Hospices billing Medicare Administrative Contractors (MACs) will want to take note of a revised rule from CMS that creates a new Common Working File (CWF) edit in Medicare systems to ensure that the provider identifier (CMS Certification Number (CCN)) on Type of Bill matches the most recent provider CCN on a hospice benefit period.
This isn’t a new policy, it simply revises Medicare systems to administer existing hospice benefit policy more efficiently, but billing staffs should be aware of the update.
CMS to Terminate CWF Eligibility Queries for HETS Users
CMS announced plans to discontinue the Common Working File (CWF) beneficiary health insurance eligibility transactions (MLN Matters® Special Edition Article SE1249) in December 2012. At the same time, CMS also announced that the HIPAA Eligibility Transaction System (HETS) would be the single source for this data. CMS subsequently delayed this effort based on feedback about the differences in data returned between the two systems and the one-year limit to HETS’ historical search capability. Since then, CMS has resolved those issues and is moving forward to phase out CWF beneficiary health insurance eligibility transactions to address the inefficiencies of maintaining two different systems returning the same data.
Beginning July 1, 2019, when you enter the required information to access beneficiary eligibility data in ELGA, ELGH, HIQA and HIQH, a new screen will display a message notifying you that beginning in the fall of 2019, CMS will terminate access to ELGA, ELGH, HIQA and HIQH for those who already use the HIPAA Eligibility Transaction System (HETS). This will affect clearinghouses, third-party billers, providers and other users.
If you currently use both CWF and HETS to get Medicare beneficiary health insurance eligibility information, CMS advises you to immediately begin using HETS exclusively.
For more information, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8248.pdf
Only the Active Billing Hospice Can Submit Revocations
CR 11049 creates a new Common Working File (CWF) edit in Medicare systems to ensure that the provider identifier (the CMS Certification Number (CCN)) on Type of Bill (TOB) matches the most recent provider CCN on a hospice benefit period. CWF will allow Notices of Revocation/Termination (NOTR) if the provider CCN on the NOTR matches the CCN on the hospice election period. This occurs even if a transfer notice has changed the billing provider on a benefit period within that election.
This is not a new policy; it revises Medicare systems to administer existing hospice benefit policy more efficiently. However, hospice providers should be aware that MACs will reject an incoming TOB if:
- The provider CCN matches the CCN on the hospice election period or matches a previous transfer or change of ownership CCN that is not the latest; AND
- Transfer or change or ownership dates are present on a hospice benefit period; AND
- No claims have been processed within the benefit period; AND
- The CCN does not match the CCN associated with the latest transfer or change of ownership date on the hospice benefit period.
MACs will return the rejected bill to the provider with a message stating that the active billing provider on the hospice benefit period must submit the revocation.
Ready or Not, the Countdown to PDGM and PDPM Is On
On October 1, 2019, the new Patient-Driven Payment Model (PDPM) will replace the Resource Utilization Group Version IV for calculating reimbursement for Skilled Nursing Facilities (SNFs). PDPM will provide a completely new way of calculating reimbursement: Payments based on patient needs rather than on therapy minutes.
CMS and eSolutions have resources available to help you learn more and prepare:
- CMS PDPM webpage, including fact sheets, FAQs, presentation, and coding crosswalks/classification logic
- Materials from the Medicare Learning Network call in December
- New Medicare Webpage on PDPM MLN Matters Article
- Implementation of the SNF PDPM MLN Matters Article
- Here Comes PDPM: Will Your SNF Be Prepared for the New Payment Model?
- PDPM Is Poised to Transform the Way SNFs Do Business – Are You Ready?
For home health agencies, PDGM is the new Patient-Driven Groupings Model, set to become effective January 1, 2020. CMS said PDGM is its attempt to better align HHAs’ operating model with a U.S. healthcare industry that is quickly evolving toward more value-based rather than volume-based initiatives. The new rules are expected to drastically change home health reimbursement when they take effect next year.
Here’s a list of resources to get more information on PDGM from CMS and eSolutions:
- CMS PDGM webpage, which includes downloadable information about case mix weights, LUPA thresholds and a Grouper Tool
- CMS white paper providing an overview of PDGM
- Counting Down to PDGM
- What is PDGM and What Will it Mean for Your HHA?
- PDGM FAQs
- Preparing for PDGM Like a Pro (Add Link to new blog)
For more information on CMS rules and changes, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2019-MLN-Matters-Articles.html#
To learn more about how eSolutions can help you automate and manage your Medicare revenue cycle, visit https://www.esolutionsinc.com/solutions/medicare