NPAG Conference, Chicago, IL September 25, 2007 Sherri McQueen, COBC Brian Pabst, CMS Donna Razor, COBC Welcome to the Coordination Of Benefits Agreement (COBA) Program Presentation
The Coordination of Benefits Agreement (COBA) Process Brian R. Pabst, MPA COBA Government Task Leader
Overview of Activity Since 2005 • All commercial payers transitioned to the new COBA process by May 1, 2006. • All State Medicaids transitioned to the new process by September 4, 2006. • Standard add/update/delete eligibility file methodology in use since April 2007. • Automated dispute file process implemented March 19, 2007.
Overview of Activity Since 2005 • Availability of a COBA claims repair process since July 2006. • Availability of a COBA Part A and B claims recovery process since January 2007. (Not available for DMEPOS or NCPDP batch claims) • New COB Agreement and Attachment available since June 2007.
The Coordination of Benefits Agreement (COBA) Process Sherri McQueen Group Health Incorporated (GHI) COBC Project Director
Role of the COB Contractor • Negotiate and Execute COBAs • Receive and Process Eligibility Files • Receive and Convert to HIPAA format • Transmit Claim Files to TPs • Process TP Claim File Disputes • Perform Invoice, Payment Reconciliation and Disbursement Activities
COBA Claim Process Flow • Medicare contractors submit all claims for crossover to the COBC nightly via 837 flat file formats and/or NCPDP. • COBC edits claims for required elements. Files that fail business edits are not processed, and the contractor is asked to re-transmit the entire file. • Accepted files are sent through a customized claims translator to convert the file to an outbound HIPAA ANSI X12N (version 40101) and perform HIPAA validation. • COBC sorts the claims by COBA IDs for transmission to the trading partners.
Eligibility File Process Flow • Step 1 - Eligibility File is received from the trading partner containing add, update and delete transactions. The COBC system performs file-level edits on the Eligibility File to either accept or reject the incoming file. The COBC database is updated with the file status of ‘A’ (Accepted) or ‘S’ (Severe error). The Eligibility Acknowledgement File (EAK) is created and returned to the trading partner indicating the file status along with an Error Description if there was a severe error. • Step 2 - COBC performs record level edit processing prior to sending the record to CWF. If a record fails the BO editing, it is not sent to CWF for further processing, and the COBC database is updated with the corresponding BO error. The BO error is transmitted back to the trading partner on the Eligibility Response File (ERF).
Eligibility File Process cont’d • Step 3 - Eligibility records with requested changes that passed COBC BO edits are applied to the COBC database. • Step 4 - COBC formats the requested changes to CWF specifications and transmits the records to the appropriate CWF host site. • Step 5 - COBC receives and processes CWF responses. All ‘01’ (accepted at CWF) responses are applied to the COBC database. COBC continues to recycle response not received and update the database on a daily basis. Once all of the CWF Response files are received or 9 business days has elapsed since the transmission of the Eligibility File, the Eligibility Response File (ERF) is returned to the trading partner. If a record is still recycling when the ERF is created, the record will have a disposition code of ‘50’, ‘52’, 60, AB, or CI. (Record still being processed by CMS). Trading partners should resubmit the record with their next file.
Sample Flow Week 1 Monday Trading partner submits Eligibility File. Tuesday Eligibility File is initially edited and Eligibility File Acknowledgement (EFA) is transmitted to the trading partner. Wednesday Eligibility File transmitted to CWF. Thursday Response received from CWF and applied to the COBC eligibility database. Friday Immediate recycles transmitted to CWF and additional responses applied to the COBC eligibility database. Note: The CWF requires that the COBC hold response records received with corrected HICNs (Disposition Code 51) and relocated beneficiary master records (Disposition Code 50) for three (3) days before retransmitting records to the CWF. This process is called “recycling.”
Sample Flow, cont’d Week 2 Monday Additional responses applied. Tuesday Retransmit records held during Week 1 (recycles), if no CWF response received to date. Wednesday Response received from CWF and applied to the COBC eligibility database. Thursday Eligibility Response File (ERF) created for transmission to trading partner. Friday Transmit ERF to trading partner
The Coordination of Benefits Agreement (COBA) Process Brian R. Pabst Sherri McQueen
Dispute File Process • Dispute files are received and processed daily in the COBA Dispute Tracking System (DTS) • Files that receive a severe error are flagged and not processed. • Upon receipt of a dispute file, an acknowledgement e-mail is sent to the TP.
Review and Resolution • Disputes are submitted at the claim level, ISA-IEA, ST-SE • Disputes are sorted by reason code within a COBA ID • 100, 110, 120 - Duplicate Claims • 300 – Beneficiary not on eligibility file • 500 - Incorrect Claim Count • 600 – Claim does not meet selection criteria • 700 – HIPAA Error • 999 - Other
Review and Resolution, cont’d • EDI representative performs analysis • Review of claim file(s), eligibility data in CWF, HIPAA validation routines, edits, etc. • Processing time is 7 business days (time vary based on the volume and type of dispute) • Upon completion of the investigation, the COBC uploads the dispute file to the COBC mainframe; e-mail notification is sent to the trading partner.
Completion of Investigation Please note: • If the investigation determines the claim(s) should not have crossed, the claim(s) is flagged as dispute resolution A – Agree. • If the investigation determines the claim(s) crossed correctly, the claim(s) is flagged as dispute resolution R – Reject. • If sufficient information is not provided to process the dispute, the claim(s) is flagged as dispute resolution I – Insufficient.
Invoice and Payment Reconciliation • Post Invoice - if the trading partner has not been billed for the claim, it will be removed from the crossover claim table and will not appear in the next invoice. • Pre Invoice - if the trading partner has already been billed for the accepted disputed claim(s), a credit is issued for the claims that can be applied to the current or future invoice. • Contractor Notification – accepted disputes are reported to the contractor in their daily detailed error report.
Provider Notification Regarding Trading Partner Disputes • Provider notification letters contain a standard message “Claim was rejected by the trading partner,” together with accompanying error code. • CMS prepared a Med-Learn Article to define all “333” rejection codes for providers. • Contractors do not issue provider notification letters for all “333” errors.
Future Enhancements • Refinements to the dispute process • Electronic dispute response file • Streamlined dispute error codes • Automated dispute analysis • Conversion of E02 process to match E01 • Acknowledgement File • One for one responses in Response File
The Coordination of Benefits Agreement (COBA) Process Donna R. Razor Group Health Incorporated (GHI) COBA Marketing Coordinator
Claim-Based Crossover • Also known as “mandated Medigap crossover.” • True Medigap plans, as defined by Section 1882(g) (1) of Title XVIII of the Social Security Act, are presently not required to submit eligibility files to identify their insureds. • Section 1842(h)(3)(b) of Title XVIII of the Social Security Act authorizes mandated Medigap crossover when a beneficiary is seen by a participating provider or supplier.
Occurs if: The provider or supplier of service participates in Medicare. The beneficiary assigns his/her benefits. A valid contractor-assigned ID is present on the incoming Part B or DME claim. Claim-Based Crossover Process
CMS anticipates that most larger Medigap plans will elect to participate completely in eligibility file-based crossover. Medigap insurers are required to sign a national COBA for receipt of a Medigap COBA ID. Medigap COBA claim-based identifier (range 55000-59999) will replace existing OCNA & N-key numbers. All assigned COBA claim-based IDs will be populated on the COBA website only after the Medigap COBA insurers have moved into production with the COBC. COBA Claim-Based CrossoverTransition Activities
CMS will alert all Part B contractors, including MACs, and DMACs via e-mail of COBA IDs on a weekly basis. The CMS alert will include the affected entity’s name, the entity’s former OCNA and N-Key identifiers; and its newly assigned COBA Medigap ID. Participating providers wishing to trigger crossovers to Medigap insurers will be required to include the new COBA identifier on their incoming Medicare claims. Failure to do so will result in claims not being successfully crossed over to the Medigap insurer. COBA Claim-Based CrossoverImplementation
COBA Provider Education Medlearn Matters Articles • Published by CMS as MM5601. • Titled “Transitioning the Mandatory Medigap (claim-based) Crossover Process to the Coordination of Benefits Contractor.” • This Medlearn article may be accessed at: www.cms.hhs.gov/MLNMattersArticles/downloads/MM5601.pdf • Published by CMS as MM5662. • Titled “Notifying Affected Parties Regarding Changes to the Mandatory Medigap (claim-based) Crossover Process. • This Medlearn article may be accessed at: www.cms.hhs.gov/MLNMattersArticles/downloads/MM5662.pdf • Both of the above articles communicate the CMS requirements for the transitioning of its mandatory Medigap (claim-based) crossover process from its Part B contractors, MACs, and DMACs to the COBC.
The Coordination of Benefits Agreement (COBA) Process Brian R. Pabst, MPA COBA Government Task Leader
Latest on Medigap Claim-based Crossovers • All Medigap insurers must be able to accept the HIPAA 837 professional claim for Medigap claim-based crossover purposes effective October 1, 2007. • Medicare will cease tagging claims for its Medigap claim-based crossover process effective with October 1, 2007.
Latest on Medigap Claim-based Crossovers (cont.) • Medigap insurers must be able to accept residual claims (claims sent to the Part B contractor or DMAC’s payment floor prior to October 1, 2007) after October 1, 2007. • CMS’ Medicare contractors will discontinue any crossover contracts with Medigap claim-based recipients no later than October 31, 2007.
Updates Concerning Major Initiatives • Present on admission indicator (available in “K3 segment” effective with January 7, 2008). • Final rule regarding new DRGs (CMS-1533-FC) http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asp#TopOfPage
Updates Concerning Major Initiatives(cont.) • NPI Issue--- CMS decision concerning allowance of legacy identifiers on 837 COB & NCPDP COB claims removed from the payment floor on/after May 23, 2008.
Visit Us on the Web! For more information regarding Medicare Coordination of Benefits Agreements visit our Web site at: www.cms.hhs.gov/cobagreement
Contact Information • CMS contact • Brian Pabst • (410) 786-2487 • Brian.Pabst@cms.hhs.gov • COBC contact • EDI Department • (646) 458-6740 • COBVA@GHIMedicare.com