REMINDER – Medicare Usage – New Rules of Behavior – IMPORTANT

REMINDER – Medicare Usage – New Rules of Behavior – IMPORTANT Medicare continues to monitor eligibility transaction volumes on the 1st and 1st Monday of each month. The purpose of this monitoring is to maintain the performance of their eligibility system, as they continue to see higher than normal transaction volumes on these days.   CMS has published modified Rules of Behavior to address the issues identified as problematic. CMS now considers the following examples of aberrant and/or unauthorized behavior to include:

1. Submitting high inquiry volume
2. Submitting transactions that receive a high error rate
3. Inappropriate use of service type codes
4. Using automated processes for sending large numbers of eligibility requests in a short period of time or high ratio of eligibility inquires to claims submitted
5. Submitting eligibility requests using the same NPI and HICN number 30 or greater times in a 24 hour period.

The full Rule of Behavior can be read at:  EligibilityTransactionSystemInquiriesRulesofBehavior.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/EligibilityTransactionSystemInquiriesRulesofBehavior.pdf

“CMS requests that all Submitters submit non-essential eligibility requests outside of peak hours. (Currently 7:00 AM – 7:00 PM ET, Monday – Friday)”.