On September 9th, the Centers for Medicare and Medicaid Services (CMS) held a webinar to provide details on its voluntary testing period related to its implementation of the Provide Accurate Information Directly (PAID) Act. This testing period begins on September 13, 2021 and runs through December 10, 2021. This webinar applied primarily to non-group health plan Section 111 reporting agents and RREs that self-report to CMS.
By way of brief background, the PAID Act, in general, requires CMS to expand its Section 111 Query Process to provide RREs with a claimant’s Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug) enrollment information.
Pursuant to the PAID Act, CMS had previously announced that it will be providing RREs with the following information as part of the Query Response File:
- Contract number, contract name, plan number, coordination of benefits (COB) address, and entitlement dates for the last three years (up to 12 instances) of Part C (Medicare Advantage) and Part D coverage; and
- The most recent Part A and Part B entitlement dates.
CMS’s webinar on September 9th was the agency’s latest activity related to its on-going PAID Act implementation plans. Prior to this webinar, CMS released information on PAID Act implementation as part of its updates contained in Section 111 NGHP User Guide (Version 6.4); Section 111 NGHP 270/21 Companion Guide (Version 5.5) and (Version 5.6); and a PAID Act Town Hall call.
With this level-set, the authors now provide a general overview of CMS’s webinar as follows:
CMS started the session by reiterating that PAID Act implementation is scheduled to go live on December 11, 2021. They then reminded the audience that they will be returning the information outlined in the bulleted items above through the Query Response File and that this information will be added to their on-line Beneficiary Lookup Tool, which RREs can access through CMS’s Section 111 COB Secure Website. On this latter item, CMS advised that the Beneficiary Lookup Tool will be updated as of October 4, 2021 to include Part A and B entitlement dates along with Part C and D enrollment data as outlined above. CMS also noted that in the event a query is performed using the Beneficiary Lookup tool involving a beneficiary who has not been enrolled in a Part C or Part D plan within the past three years, the related field will simply display the indication “no records found.”
With respect to how often CMS would update plan enrollment information as part of the Query Response File, CMS explained that they receive updated information via a nightly feed and that it would likely only take a matter of days for any changes to be reflected in response data. CMS also noted that there were no plans to add Part C and D enrollment data to the MSPRP. Also, CMS deferred comments regarding whether Part C and Part D plans were expected to make changes to their recovery processes in relation to the PAID Act. On these questions, CMS instructed interested parties to submit their inquiries to Part C and D Mailboxes as follows: Part C Mailbox: https://dpapportal.lmi.org/DPAPMailbox/ and Part D Mailbox: PartD_COB@cms.hhs.gov
HEW Software matters
CMS spent a fair amount of time discussing changes related to their free HIPPA Eligibility Wrapper (HEW) software. As part of this discussion, CMS noted that the new PC Version 5.0 will be made available for download as of September 13, 2021 via the Reference Materials drop down menu on their Section 111 COB Secure Website. CMS instructed those RREs who will require the updated version of the mainframe software to contact their assigned BCRC EDI representatives who will provide copies, directly, upon request.
In addition, CMS confirmed for the attendees that the new PC Version 5.0 will allow for parallel installation alongside the prior version of the HEW Software. This will make it possible for RREs to continue using the prior version of the HEW software for their production submissions, from 9/13/21 through 12/10/21, while simultaneously using Version 5.0 for testing during that same timeframe. CMS noted further that for any files submitted 12/11/21 or later, RREs may then begin using the new Version 5.0 for their production submissions. It was also noted that, if RREs were to attempt to continue to use the prior version of the HEW software for files submitted 12/11/21 or later, the software would output log error messages regarding unexpected X12 elements but would still export a file. However, that file would be truncated at 300 bytes (the record length of current Query Response Files) and none of the expanded data would be included.
CMS also indicated that to receive the expanded response data, RREs will need to utilize either the updated Version 5.0 of the HEW software or, if using their own EDI translator software, would need to update their EDI X12 mapping according to the specifications provided in the recently updated version of the NGHP Companion Guide. Additionally, CMS suggested RREs using their own translator software and not wanting to take advantage of the expanded response data, may still need to make updates to their 271 mappings to successfully translate the response files as of 12/11.
As part of its discussion, CMS indicated several times that while RREs are not required to integrate the HEW software update at this time, the agency noted that subsequent versions of the HEW software may append to this new version. CMS also indicated that they could not offer a definitive timeframe regarding how long the current version of the HEW software would be in effect. On this point, they suggested that it may not continue to work properly after subsequent revisions to Version 5.0 are published.
PAID Act – testing specifics
Regarding testing specifics, the authors outline the following selected points of likely interest as discussed by CMS:
- The testing period will begin on September 13, 2021 and continue through December 10, 2021.
- Changes will be live in production as of December 11, 2021 but RREs who prefer to perform additional testing may continue to do so following this date.
- While testing is not required, it is encouraged by CMS.
- RREs were directed to the Section 111 NGHP User Guide (Version 6.4, June 11, 2021), Chapter IV, Section 9 for full information regarding general testing procedures.
- CMS noted several resources to assist RREs with the testing process. These are available for download via the Reference Materials file menu on the CMS Section 111 COB Secure Website under the Test Data for NGHP RREs heading, including:
- Test Beneficiary List –CMS noted that this is the same test beneficiary data that has been provided in the past but may now be used for PAID Act testing.
- Sample NGHP X12 271 Query Response File – CMS noted that this is a sample Query Response File, containing “dummy” data, which can be used to test the new EDI translator, either HEW or another translator with updated mapping, for the new expanded query response process.
CMS outlined the following important dates related to PAID Act testing:
- Test Beneficiary List – Available Now
- Sample 271 Response File – Available Now
- HEW Version 5.0, both PC and Mainframe versions – Available September 13, 2021
- Testing Period – September 13 – December 10, 2021
- Section 111 COBSW Online Beneficiary Lookup Tool Updates – October 4, 2021
- Production Implementation of PAID Act 271 Response File Changes – December 11, 2021 (only files submitted 12/11 or later will contain expanded data)
CMS has released a copy of its presentation which can be obtained here.
For our MSP Navigator, ClaimSearch, and iComply Section 111 reporting customers
As noted above, this webinar applied primarily to Section 111 reporting agents and RREs that self-report to CMS. For our ISO Claims Partners’ MSP Navigator, ClaimSearch CMS and iComply customers, please note that each one of our referenced reporting solutions will undergo thorough testing with CMS during the testing period. Thus, our reporting customers will not be required to test directly with CMS. Rather, testing for all ISO reporting customers should primarily focus on the receipt and processing of the expanded query response data to be returned via the above referenced ISO reporting platforms. Further details regarding ISO specific testing will be forthcoming very shortly.
Feel free to contact the authors if you have any questions regarding the information discussed above or the PAID Act in general. ISO Claims Partners continues to closely monitor CMS’ PAID Act implementation and will provide future updates as warranted.
 CMS’s Section 111 NGHPUser Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1. It is noted that CMS will actually be providing RREs with more information than required under the PAID Act. On this point, the PAID Act, in general, requires CMS to expand the Section 111 Query Process to (i) identify whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the Medicare program; and if so, (ii) provide the RRE with the plan name and address of any Medicare Advantage plan under Part C and any prescription drug plan under part D in which the claimant is enrolled or has been enrolled during such period. H.R. 8900, Further Continuing Appropriations Act, 2021, and Other Extensions Act, (ii). However, while the PAID Act only requires that CMS provide “the plan name and address” of any identified Medicare Advantage or Part D plan, CMS will also be providing RREs with the contract number, contract name, plan number, and the plan’s COB address. In addition, CMS will be providing the most recent Part A and Part B effective and termination dates. CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.