Last Modified: 2/3/2021
Location: FL, PR, USVI
Business: Part A, Part B
On February 7, 2017, and July 15, 2018, the Centers for Medicare & Medicaid Services (CMS) issued notifications to all Coordination of Benefits Agreement (COBA) trading partners concerning the Next Generation Accountable Care Organization (NGACO) Model demonstration project (including information regarding the All-Inclusive Population-Based Payment (AIPBP) aspect of the project). These notices emphasized the significance of Claim Adjustment Reason Code (CARC) 132, including what its presence signified.
CMS is re-alerting all COBA trading partners to critical information about the NGACO Model demonstration project, which has been activated within the traditional Medicare program.
The aim of the NGACO Model is to improve the quality of care, population health outcomes, and patient experience for the beneficiaries who choose traditional Medicare fee-for-service (FFS) through greater alignment of financial incentives and greater access to tools that may aid beneficiaries and providers in achieving better health at lower costs.
The purpose of the NGACO Model (also known as the "Next Generation Model," "Next Generation," or the "Model") is to test whether strong financial incentives for ACOs can improve health outcomes and reduce expenditures for Medicare FFS beneficiaries. The Model offers financial arrangements with higher levels of risk and reward than current Medicare ACO initiatives, using refined benchmarking methods that: (1) reward quality performance; (2) reward both attainment of and improvement in cost containment; and (3) ultimately transition away from reference to ACO historical expenditures. The Model additionally offers a selection of alternative payment mechanisms to enable a graduation from FFS reimbursements to capitation.
• NGACO applies to both 837 institutional and professional claims.
• NGACO 837 crossover claims will include demonstration project code 74, reported in REF02 of 2300 REF (Demonstration Project Identifier), where REF01=P4.
• Increasingly, Medicare NGACO claims may be paid through an alternative payment mechanism with the Next Generation ACOs called All-Inclusive Population-Based Payment (AIPBP). In such cases, the claims will feature CARC 132 on them.
• COBA trading partners can tell an NGACO is participating in AIPBP by the presence of a Medicare payment amount of $0 and an amount qualified by Group Code "CO (Contractual Obligation)" and CARC "132." Important: The $0.00 paid amount does not mean that Medicare denied the claim.
• The presence of CO-132 means the NGACO, rather than Medicare, is directly paying the provider of service. Therefore, Medicare's payment amount is reflected as $0. By no means should COBA trading partners deny claims with CARC 132, proceeding under the assumption that Medicare itself denied the claims.
• CMS requests COBA trading partners which may not have paid NGACO (Demo 74) claims because they contained CARC 132 and an associated amount of $0.00 to reprocess the affected claims.
• This notice is of highly critical importance. We ask our COBA trading partners take any necessary systems actions to ensure they will no longer regard NGACO claims containing CARC 132 (CO-132) and an associated amount of $0.00 as "not paid by Medicare."
The Benefits Coordination & Recovery Center (BCRC) houses the COBA trading partner's information for crossover purposes. Direct questions regarding this notification to the BCRC's Electronic Data Interchange (EDI) Department.
Source: BCRC COBA EDI Department
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