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CMS releases new Section 111 alert regarding SSNs

The Centers for Medicare and Medicaid Services (CMS) has released a new NGHP Section 111 alert (dated November 25, 2014) providing additional information regarding its plans to allow RREs to submit partial social security numbers (SSNs) for Section 111 purposes beginning January 5, 2015.

The authors outline this important development and related considerations as follows:

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Background

By alert dated September 10, 2014, CMS first announced that it would allow RREs to submit the last five digits of an individual’s SSN (as opposed to the full SSN) beginning January 5, 2015. This policy change was prompted by Section 204 of the SMART Act, which calls on CMS to eliminate the required use of SSNs for Section 111 reporting purposes.

The September alert provided only a general outline of this new policy, with the agency advising that further instructions would be released in a subsequent alert.  These additional instructions are now contained in the November 25, 2014 alert.

CMS’ new Section 111 SSN policy

CMS’ new policy, as stated in the November 25th alert, can be broken down as follows:

  • Effective January 5, 2015, where a NGHP RRE cannot obtain an individual’s HICN or full SSN, the RRE may report the last 5 digits of the claimant’s SSN, along with the claimant’s first initial, surname, date of birth, and gender.
  • NGHP RREs may continue to submit the HICN or full SSN as before without making any changes to the field and file formats.
  • The full HICN will continue to be returned if a distinct match to a beneficiary is found, regardless of whether a full or partial SSN was submitted.
  • If an RRE is unable to obtain the HICN or full/partial SSN, they must document their attempts to obtain this information. CMS has revised its Model Language to account for an RRE’s attempt to obtain the partial SSN.

We have been planning for this change and we are prepared to accept either full or partial SSNs for Query and Claim Input Files when CMS’ new policy becomes effective on January 5, 2015.

It is also noted that CMS introduces some technical changes in this alert, but those changes will have absolutely no impact for RREs that are reporting their claims through our MSP Navigator.

Practical considerations

In taking a practical look at CMS’ new alert, it should first be noted that if an RRE wants to continue submitting a claimant’s full SSN, it may continue to do so.  Further, regardless of whether a full or partial SSN is submitted, CMS will continue to return the full HICN if a distinct match is found.

It is also important to note that if an RRE is unable to obtain a claimant’s HICN, or full or partial SSN, CMS states that the RRE “must” document their attempts to obtain this information. As part of this, CMS has updated its model language.  This resurrects long standing issues in Section 111 circles such as, what measures RREs should take to obtain SSN/HICN information, how best to document a claimant’s refusal to provide this information, how often these attempts should be made, etc.

Regarding the Model Language itself, CMS first introduced this process via alert back in August, 2009 to help RREs in their attempts to obtain a SSN/HICN from claimants. While use of the Model Language process does not provide a  “safe harbor,” CMS states that it will consider an RRE compliant for purposes of its next Section 111 file submission in certain situations when the Model Language is used, as more fully outlined in the August 2009 alert.

Updated Model Language

CMS has now updated the Model Language to account for RRE efforts to obtain a claimant’s partial SSN. Specifically, the updated language includes the following new verbiage: “Note: If you are uncomfortable with providing your full … (SSN), you have the option to provide the last 5 digits of your SSN in the section above.” 

From a more global view, a related matter that CMS does not address in its new Alert, but which continues to loom large over this entire area, is the issue of good faith “safe harbors.” Specifically, Section 203 of the SMART Act requires CMS to establish compliance safe harbors protecting RREs from Section 111 penalties in situations where they are unable to determine a claimant’s Medicare beneficiary status despite good faith efforts to do so.

CMS is currently in the process of drafting its “good faith” safe harbor proposals, as part of its larger efforts of developing its general Section 111 penalty proposals.

On a final note, CMS is scheduled to address its new Section 111 SSN policy as part of its upcoming Section Town Hall call on December 10, 2014.

We will be attending the December 10, 2014 Town Hall call and we will release updates on CMS’ new SSN policy, as well as other Section 111 developments, as warranted.


Mark Popolizio, J.D.

Mark Popolizio, J.D., is vice president of MSP compliance, Casualty Solutions at Verisk. You can contact Mark at mpopolizio@verisk.com.


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