The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP 270/271 Companion Guide (Version 5.6, July 22, 2021) (also referenced herein as “Companion Guide”).[1] Version 5.6 of the Companion Guide now replaces Version 5.5 which CMS published on June 11, 2021. Overall, in Version 5.6 of the Companion Guide CMS makes minor technical corrections to certain data specifications originally published in Version 5.5 related to the agency’s PAID Act implementation plans.
Briefly, CMS’s Section 111 NGHP 270/271 Companion Guide, which has been in existence since the start of the Section 111 reporting process, is intended for use by RREs who choose to utilize their own EDI translator software to perform their X12 270/271 translation and not the HIPPA Eligibility Wrapper (HEW) software which CMS makes available free of charge. Historically, CMS has published this Companion Guide in conjunction with the file layout specifications utilized for their HEW Software process as outlined by CMS in the Section 111 NGHP User Guide, Chapter V (Appendix E). In June 2021, CMS released updates to the Companion Guide as part of its Version 5.5 updates to provide EDI X12 271 mapping for the expanded query response data elements that are being added as a part of CMS’s PAID Act implementation.
As a refresher, per the PAID Act, CMS will be providing RREs with the following information through the Query Response File: The contract number, contract name, plan number, coordination of benefits (COB) address, and entitlement dates for the last three years (up to 12 instances) regarding a claimant’s Medicare Part C (Medicare Advantage) and Part D (prescription drug) coverage. In addition, CMS will be providing the most recent Part A and Part B entitlement dates.[2] The PAID Act implementation is scheduled to go-live on December 11, 2021. To learn more about the PAID Act and CMS’s implementation plans, see our recent articles CMS discusses PAID Act implementation plans and timelines on webinar and PAID Act – current status and FAQs.
With this backdrop set, the authors now provide a general overview of the updates made by CMS in Version 5.6 of the Companion Guide as follows:
Companion Guide (Version 5.6) updates
The updated corrections made by CMS relate to Tables 26 and 27 to the EDI X12 271 specifications regarding the agency’s PAID Act implementation plans.
CMS describes the Version 5.6 updates as follows:
The Part D Prescription Drug Enrollment Data (Table 27) has been updated to display the correct Segment IDs. Additionally, the date ranges for the Part C and Part D Enrollment and Termination Dates now include only a single dash instead of a double dashes (Table 26 and Table 27).
The following will become effective December 11, 2021:
In 2020, the Provide Accurate Information Directly Act (PAID Act) was passed to help NGHP Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates. To support this Act, the HIPAA Eligibility Wrapper (HEW) software will be updated and the X12 271 query formats will be modified to extract the additional fields (see 271 Eligibility Response Companion Document).[3]
While CMS references that “corrections” have been made to Tables 26 and 27, they did not provide a line-item listing of each corresponding correction made.
From the authors’ review of these tables in Version 5.6 of the Companion Guide, the corrections made by CMS include the following:
- Table 27 Segment ID Corrections
- Element ID EB01 – Segment ID corrected to reflect value of ‘EB’
- Element ID EB04 – Segment ID corrected to reflect value of ‘EB’
- Element ID REF01 – Segment ID corrected to reflect value of ‘REF’
- Tables 26 and 27 Valid Value(s) and Format Example Corrections (the following corrections were applied to the same data elements in both tables)
- Date ranges previously displayed as “CCYYMMDD -- CCYYMMDD” have been corrected to display as “CCYYMMDD - CCYYMMDD”.
- Element ID DTP02 – date range corrected in “Valid Value(s)” column
- Element ID DTP03 – date range corrected in “Format Example” column
- Date ranges previously displayed as “CCYYMMDD -- CCYYMMDD” have been corrected to display as “CCYYMMDD - CCYYMMDD”.
Importantly, please note that the corrections outlined above by the authors are those they have identified as part of their comparison between Version 5.6 and Version 5.5 of the Companion Guides However, in an abundance of caution, the reader should also perform his/her own independent comparisons and review of Tables 26 and 27 to ensure that no other corrections or changes were made. In any event, the information as stated by CMS in Tables 26 and 27 in Version 5.6 of the Companion Guide is the most current and operative information and guidance from CMS.
As noted above, the changes made in Companion Guide Version 5.6 relate only to those RREs who choose to utilize their own EDI translator software as opposed to CMS’s free HEW application. To the extent any of these reporters had already started to make coding changes based off Version 5.5 of the Companion Guide, adjustments may be now required per CMS’s corrections as stated in Version 5.6. For those reporters who had not yet applied the changes contained in Version 5.5, they should reference Version 5.6 of the Companion Guide for CMS’s updated guidance.
For our MSP Navigator, ClaimSearch, and iComply Section 111 reporting customers
Please note for those RREs utilizing any of ISO’s Section 111 reporting platforms (MSP Navigator, ISO ClaimSearch or iComply) to facilitate their Section 111 reporting, these changes will have no direct impact. As ISO facilitates the EDI X12 translation required for CMS’ query process via our own internal processes, ISO will be making all appropriate adjustments and the changes made by CMS in the new Companion Guide will require no action on the part of our MSP Navigator, ClaimSearch or iComply customers.
Questions?
Of course, please do not hesitate to contact the authors if you have any questions. Also, feel free to contact the authors if you have any questions regarding the latest update on the PAID Act.
[1] The authors note that the full name of this guide is “270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities. However, in practice this resource is commonly abbreviated. In this regard, the authors reference this guide as the “Section 111 NGHP 270/271 Companion Guide” or simply as the “Companion Guide.”
CMS states the “purpose” of this guide as follows:
This guide provides the Medicare COB System Interface Specifications for use by Medicare Secondary Payer (MSP) Non-GHP entities, e.g., liability insurance (including self-insurance), no-fault insurance and workers’ compensation Responsible Reporting Entities (RREs), reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111).
The process requirements detailed in this guide must be followed by Non-GHP entities in order to submit an eligibility benefit inquiry to the BCRC and receive an eligibility benefit response. This guide is intended to be used as a companion document to the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 (005010X279A1) Implementation Guide. The specifications listed are clarifications that are allowed within established HIPAA transaction sets. The BCRC will only accept and send data in the allowed ASCX12 transaction format that is allowed by HIPAA regulations and guidelines.
This document does not outline all data segments and elements that are in the HIPAA transaction set guide. This document only addresses segments as they apply to the BCRC.
CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1. (CMS emphasis).
[2] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.
[3] Section 111 NGHP 270/271 Companion Guide (Version 5.6, July 22, 2021) at 2.
