10.26.2015 – Once again we want to remind our provider community of the concerns that CMS continues to have related to the volume of eligibility transactions being processed through the Medicare System( HETS) on the 1st of the month. There are two areas of concern from CMS that we want to bring your attention to:
- Volume of transaction submitted to CMS on the 1st of the month and/or the 1st Monday of the month between the hours of 7AM -7PM EST.
- Volume of repetitive transactions that have the same NPI and HIC number submitted on the same day as well as the 1st of the month and or the 1st Monday of the month between the hours of 7AM -7PM EST. CMS currently has the threshold targeted at 30 transactions with this combination.
Last month CMS notified us of a New AUDIT process that began with transactions submitted on October 1st. It is our understanding that the above processes will remain in place until CMS releases their new system, estimated to be Fall 2016. These audits may result in the suspension of an NPI being able to submit eligibility requests until a Corrective Action Plan is submitted and approved by CMS.
What is Experian Health doing to address CMS concerns:
- Batch files sent to Experian Health on the 1st of the month or 1st Monday of the month will process normally if submitted outside of 7am-7pm ET. All Medicare batches sent to Experian Health during the 7am-7pm ET window will begin processing after 7pm ET. Please know that your responses maybe delayed based on these changes.
- CMS did not send out letters in October to submitters identified as the highest volume submitters. We have been told by CMS that this is still a concern and the same processes from October continue to be followed. CMS is asking that all non-urgent (non-urgent can be considered a patient is not seeking care the same day) eligibility transactions not be submitted on the 1st or 1st Monday of the month between the hours of 7AM-7PM ET.
- Our technical teams are working to reduce multiple transactions for the same NPI/HICN combination. Some providers have been identified as submitting what CMS is considering a repetitive transaction, same NPI/NICN combination . Individual providers will be contacted by an Experian Health team member if you have been identified by CMS.
What can you do to address CMS concerns:
- Any Batch file scheduled to be sent on the 1st or 1st Monday of the Month should be rescheduled to process later in the evening, after 7:00 PM EST or another day.
- CMS is asking that all non urgent, ( non urgent can be considered, a patient is not seeking care the same day) eligibility transaction not be submitted on the 1st or 1st Monday of the month between the hours of 7Am-7PM ET.
- Eligibility transactions should not submit for the same NPI/HICN combination more than 25 times on the same day, especially on the 1st or the 1st Monday of the month between the hours of 7AM-7PM EST.
These initiatives should improve the performance of Medicare’s eligibility processing until they can release their new system estimated to be late 2016. If you have any questions please feel free to contact your Account Manager, Sales Representative or customer support.
