CMS Alert: Matching Criteria for SSNs

On June 18, 2015, CMS issued an Alert entitled "Modification of Matching Criteria Used When Reporting Partial Social Security Numbers for Liability Insurance (Including Self-Insurance), No Fault Insurance, and Workers’ Compensation."  The text of that alert is copied below:

New Matching Criteria for Partial SSNs
In order to determine if individuals are Medicare beneficiaries, the following information is used:
•HICN or SSN
•First initial of the first name
•First 6 characters of the last name
•Date of birth (DOB)
•Gender

Effective immediately, the matching criteria for partial SSNs will be changed. When an exact match on the partial SSN is found, then four out of the four remaining data elements must be matched to the individual exactly. The matching criteria for HICNs and full SSNs will remain the same.

Reporting Compliance Considerations
NGHP RREs are encouraged to submit the HICN or full SSN when available to ensure the most accurate match is attained. Failure to match to a Medicare beneficiary with the full or partial SSN does not negate the RRE's Section 111 mandatory reporting requirement when a reportable claim exists.

The entire alert can be found here.

Section 111: Rule on Penalties Not Expected Until December 2016

Under the SMART Act, CMS is supposed to issues rules specifying "practices for which sanctions will and will not be imposed."  In December, 2013, CMS issued an Advanced Notice of Proposed Rulemaking seeking comments on circumstances in which penalties should and should not be imposed.  The comment period closed in February, 2014 and since then the industry has been awaiting proposed rules from CMS.  After CMS issues proposed rules, the public will be allowed to submit comments during a 60 day period, and then CMS will issue final rules.

Previously, CMS had indicated that they would issue proposed rules in July, 2015.  However, CMS has now indicated that they will not be issued until December, 2016.  Of course, it is possible that this time frame will change again and that CMS will issue proposed rules at a later date.  We will continue to keep you updated and let you know once any proposed and final rules are issued.  Until they are, RREs should focus on ensuring that they are reporting under Section 111 correctly and not be overly consumed with fear of retribution from CMS.
If you have questions or would like an audit of your Section 111 reporting program and processes, please let us know and we will be happy to help.

CMS Issues Updated Section 111 NGHP User Guide

On January 5, 2015, CMS issued an updated Section 111 NGHP User Guide (version 4.4).  The new User Guide incorporates the previous Alerts on reporting partial SSNs.  As we discussed in previous posts, beginning January 5, 2015, where a NGHP RRE cannot obtain an individual’s HICN or full SSN, the RRE may report the following data elements that will enable CMS to properly identify a Medicare beneficiary:

•Last five digits of SSN

•First Initial

•Surname

•Date of Birth

•Gender

The new User Guide was also updated to show that for liability claims not involving ORM, RREs will receive the CJ07 error code for reporting liability TPOCs with TPOC dates on or after October 1, 2014, with a cumulative TPOC amount less than or equal to the current $1,000.00 threshold.  Previously, RREs could optionally report below-threshold liability TPOCs with TPOC dates on or after October 1, 2014, if the cumulative TPOC amount was more than $300.00.  CMS also included new tables in the section in the User Guide on the liability TPOC threshold (section 6.4.3).  The new Table 6-5 shows liability TPOC reporting requirement for TPOC dates since October 1, 2011, along with information on optional reporting for below-threshold liability TPOCs with TPOC dates prior to October 1, 2014.  The new Table 6-6 shows when RREs will receive the CJ07 error code for reporting below-threshold liability TPOCs.

December 10, 2014 alert can be found here.
* Updated to include the link to the current NGHP User Guide, found here.