Last Modified: 12/13/2017 Location: FL, PR, USVI Business: Part A, Part B
HETS application: Updated MSP insurance type codes and inclusion of QMB data
The Centers for Medicare & Medicaid Services (CMS) released several changes to the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS), which went into effect November 4, 2017. The changes impacted providers who use First Coast Service Options’ (First Coast’s) Secure Provider Online Tool (SPOT) to access eligibility data through HETS. The eligibility display in SPOT now includes a tab titled QMB.
Updated MSP insurance type codes
HETS 270/271 now returns two additional Medicare Secondary Payer (MSP) insurance type codes for applicable Medicare beneficiaries. The codes that can be returned in the 2110C EBO4 element are:
• AP – Auto Insurance Policy; this indicates a no-fault Medicare Set-Aside Arrangement (NFMSA)
• LT – Litigation; this indicates a Liability Medicare Set-Aside Arrangement (LMSA)
HETS 271s may include QMB data
In order to help providers more readily identify the Qualified Medicare Beneficiary (QMB) status of each patient and support providers’ ability to follow QMB billing requirements, HETS 271 responses now indicate periods during which the beneficiary is enrolled in the QMB program. QMB-enrolled beneficiaries are dually eligible for both Medicare and Medicaid. Beneficiaries who are enrolled in the QMB program are not liable for Medicare co-insurance or deductible payments. Submitters should note that when the 271 2110C EB04 = QM, the DTP segment will reflect only periods of QMB enrollment within the calendar year or spell. Note that QMB status may fluctuate for a minority of beneficiaries.
If the HETS response indicates the beneficiary QMB enrollment has terminated, please verify the patient’s QMB status through state online Medicaid eligibility systems or other documentation, including Medicaid Identification cards and documents issued by the state proving the patient qualifies for the QMB program.
QMB periods are only returned in the 271 when the beneficiary has the appropriate Medicare entitlement and the QMB enrollment intersects at least one of the following:
• One day within a calendar year contained in the request date(s) or unique date of earliest billing activity (DOEBA) year of any spell being returned
• The DOEBA-date of latest billing activity (DOLBA) of any spell being returned
• The current date
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