Last Modified: 9/5/2018 Location: FL, PR, USVI Business: Part A, Part B
Eligibility data variances between HETS and the CWF FAQ
Q: The home health episode end date shown on SPOT differs from the discharge date for the same episode listed in the CWF. Why would eligibility information displayed by the portal differ from the same type of data retrieved from a CWF inquiry?
A: The causes of any variances in eligibility data returned by the Secure Provider Online Tool (SPOT) and by the Common Working File (CWF) may be understood by clarifying what happens when an eligibility query is submitted through the portal as well as the different sources for eligibility data for SPOT and the CWF.
The source for all benefits and eligibility information for SPOT is the Centers for Medicare & Medicaid Services’ HIPAA Eligibility Transaction System (HETS) not the CWF. Although the primary source for eligibility information obtained through First Coast’s interactive voice response system (IVR) system is also HETS, the IVR also retrieves some information from the Common Working File (CWF), including hospice data, home health data, and skilled nursing facility (SNF) data.
Connecting to HETS through SPOT
When a user submits an eligibility query through the portal, a direct connection is established with HETS, and HETS returns the eligibility data available at the time of the request.
The SPOT application is only the interface that connects the user to HETS. HETS is the source of the eligibility data that is returned, and the portal application displays the information. Therefore, if certain eligibility data is not available in HETS at the time of the query, that data cannot be displayed through the portal.
Eligibility data sources
HETS obtains eligibility data from CMS’ beneficiary eligibility databases. The beneficiary eligibility databases, which include the Social Security Administration (SSA) database among others, are considered the authoritative source for the following beneficiary information:
• Part A eligibility effective and termination dates
• Part B eligibility effective and termination dates
• Inactive period effective and termination dates (when applicable)
• Demographic data (e.g., address, date of birth)
• End-Stage Renal Disease (ESRD) effective date, benefit description type code, and transplant discharge date (when applicable)
• Managed Care Organization (MCO) information (when applicable)
Note: Authoritative Source -- the system or systems in which the data originated and is shared with other systems
The CWF, which is a Medicare claims processing system, is the authoritative source for other eligibility data, which includes information related to:
• Medicare secondary payer (MSP)
• Home Health
• Skilled nursing facility (SNF)
Data sharing between HETS and other systems
The CWF shares eligibility data with HETS through a nightly data exchange with CMS’ eligibility databases. Since updates to HETS from the CWF are based primarily on finalized claims, any claims-based data returned on a HETS eligibility query is only as current as the claims that have been processed by CWF. If a claim has not been finalized, the information in the CWF may be changed prior to the claim’s adjudication, which may cause variances between the information retrieved by HETS (via SPOT) and by the CWF at any given time.
Another cause of variances between eligibility data retrieved from HETS queries through the portal and data retrieved from CWF inquiries may also be due to delays -- which may be up to 48 hours -- in the sharing information between the authoritative sources of the nightly exchanges of eligibility data with HETS.
In addition, the timely submittal of claims by providers directly impacts the accuracy and timeliness of the eligibility data returned. For example, although the Home Health Episode History (HHEH) start and end dates are medically based, system updates to HETS regarding this information are still dependent upon billing activity and the finalization of the claim in the CWF. The date of earliest billing activity (DOEBA) and the date of latest billing activity (DOLBA) are based upon the claim information associated with the spell of illness requiring home health care services. Once the DOLBA claim information has been submitted, the claim has been finalized, and HETS has been updated, the CWF and HETS should display the same information regarding discharge (i.e., HHEH End Date) information.
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