CMS Issues Technical Alert and User Guide Update
CMS issued a technical alert dated November 12, 2020 titled “Revisions to Section 111 Edits to no Longer Cause Record to Reject.” This alert was accompanied with the release of the NGHP User Guide version 6.1 dated November 10, 2020.
Summary:
First, let us begin with a quick summary of the changes CMS has made within the technical alert:
- CMS has redefined the following error codes as “soft edits” in the technical alert: CC05, CC11, CC12, CC13, CC31, CC33, CC45, CC51, CC53, CC65, CC71, CC73, CI02, CI03, CI25, CP03, CP06, CP07, CP08, CP09, CP10, CR11, CR12, CR13, CR31, CR32, CR33, CR51, CR52, CR53, CR71, CR72, CR73, CR91, CR92, CR93, & CR94.
- CMS is creating a new error code CP13 to indicate the no-fault insurance limit that was submitted is less than $1,000.00.
- For all the error codes indicated above, CMS will document the errors in the error fields of the claim response file, but the errors will not cause the claim(s) to be rejected.
Additional changes that were not noted in the technical alert were found in the update to User Guide 6.1 as follows:
- Claim input file detail records that are submitted prior to the effective date of the injured party’s entitlement to Medicare will now be returned with a disposition code of 03 instead of an SP disposition code and the associated SP31 error code.
- The User Guide update also includes a longer listing of error codes that will result in the claim being accepted instead of rejected with errors. These are: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP03, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30.
- ***Important to note that although CMS seems to have coordinated the release of the alert with the User Guide update, the User Guide list of error codes that will now be considered “soft errors” includes nine additional codes of CC25, CC32, CC52, CC72, CR14, CR34, CR54 and CR74.
- These changes will go into effect on April 5, 2021.
Deeper Dive:
On the surface these updates may not appear to be a huge shift for CMS, but let’s start out with the fact that this represents the first time for NGHP reporting where records with errors will be returned to the RRE in a non-SP disposition status. NGHP Solutions has confirmed with the BCRC that this is new practice for the NGHP side of Section 111 reporting although it has been happening for GHP reporting. For any service provider, or RRE performing their own reporting, a review of the data flows should be performed to ensure the new combination of codes is being handled correctly when response files are returned.
NGHP Solutions, upon contacting the BCRC, also inquired as to the wording in User Guide 6.1 stating “RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission.” As these are called either “soft edits” or “soft errors,” depending on whether you are reading the alert or the User Guide, the question was posed as to what type of compliance issue an RRE might face if the errors were not corrected. The BCRC responded that, at this time, CMS is not looking to enforce the correction of this data as the fields are optional either directly or indirectly.
Another process review should be performed regarding the change CMS is making to return disposition code 03 instead of the disposition code SP with SP31 error code combination. The guidance around SP31 errors has been to simply resubmit the claim in the next quarterly file. Now, the claim will fall under disposition code 03 guidance which means claims submitted will be handled differently for ORM and no-ORM statuses. While most processes will have been handling these scenarios for some time, the additional volume of claims falling into disposition 03 may facilitate a review to ensure the claims are being handled appropriately.
“The Elephant in the Room”
It would be irresponsible at this point to not evaluate any updates from CMS in the context of looming rulemaking around civil money penalties. In our response to CMS for the rulemaking, NGHP Solutions pointed out that CMS should consider processing all claim files without limitation by an artificial error threshold of twenty percent. While these changes do not do that, they may reduce the number of claims returned in SP disposition status which would make it more difficult to hit the twenty percent threshold. The movement of certain error codes to soft status seems to be a way of reducing rejected claims over data elements CMS knows are optional. It is unclear how many RREs are still reporting data elements that are optional in all circumstances, like the alleged cause of injury code and text description, so these changes may not be beneficial to all entities sending CMS quarterly files. Also, for well-tuned reporting systems, the SP31 error has remained a burden as it may represent the vast majority of SP disposition codes returned. The argument can be made here that CMS is attempting to make error counts in files more relevant in preparation for civil money penalties.