A/B MACs and DME MACs Contractor MSP Auxiliary File Update

10.1 - A/B MACs and DME MACs Contractor MSP Auxiliary File Update Responsibility (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) The capability to update the CWF MSP auxiliary file is, essentially, a function of only the MSP Contractor. A/B MACs and DME MACs do not have the capability to delete any MSP auxiliary file records, including those they have been established. If they believe a record should be updated or deleted, they shall use the MSP Contractor ECRS Web (discussed in §10.2) to update the MSP record. Below are some examples where the A/B MACs and DME MACs may need to create and send an ECRS request. They are: 1 - The A/B MACs and DME MACs receive a piece of correspondence from a beneficiary representative, beneficiary, third party payer, another insurer's explanation of benefits or other source, or phone call from the provider, that establishes, exclusive of any further required development or investigation that MSP no longer applies. A termination date is included in the correspondence or provided by phone. The A/B MACs and DME MACs shall submit an ECRS request to the MSP Contractor with the appropriate termination date identified within forty-five (45) calendar days of the mailroom date-stamped receipt/date of the correspondence, as applicable. EXAMPLE Scenario Union Hospital is calling the A/B MAC (Part A) to report that the group health plan MSP period contained on the CWF for beneficiary X should be terminated. A/B MAC (Part A) Action The A/B MAC (Part A) shall check for a matching auxiliary record on CWF and initiate the CWF assistance request to the MSP Contractor to terminate the record. 2 - The A/B MACs and DME MACs receive a GHP claim for secondary benefits and could, without further development (for example, the explanation of benefits from another insurer or third-party payer contains all necessary data), add an MSP occurrence and pay the secondary claim. The A/B MACs shall use a validity indicator of "I" to add any new MSP occurrences (only if no MSP record with the same MSP type already exists on CWF with an effective date within 45 days of the effective date of the incoming "I" record). An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. Note, Dark Days, or some federal holidays, may impact the time frame for uploading an “I” record to CWF. The A/B MAC and DME MAC contractors shall retain suspense dates and be able to provide either screen prints or create upon request a report reflecting all status dates of claim suspensions. Note: Managing the MSP inventory of workload in such a way as to require all MSP related claims be processed within 10 calendar days from the date in which the claim suspends for MSP will ensure the CMS requirement for the creation of “I” records is consistently met. The A/B MACs shall not submit a new record with a "Y" or any record with an "N" validity indicator. The DME MACs shall submit an MSP Inquiry, or Assistance Request if applicable, within ten (10) calendar days from the last day when the claim is suspended for MSP (internal system or CWF, whichever suspends first), for MSP, or within 45 calendar days of receipt of the claim. Invalid values are not allowed in the following critical fields for any ECRS entries: HICN, MBI, MSP Type, MSP Effective Date, Patient Relationship and Insurer Name. 3 - The A/B MAC receives an NGHP claim for conditional payment, and the claim contains sufficient information to create an "I" record without further development. The A/B MAC shall add the MSP occurrence using an "I" validity indicator. An “I” record is to be added to the CWF within 10 calendar days when the claim is suspended for MSP (internal system or CWF, whichever suspends first) if no MSP record with the same MSP type already exists in CWF. The A/B MAC and DME MAC contractors shall retain suspense dates and be able to provide either screen prints or create upon request a report reflecting all status dates of claim suspensions. Note: Managing the MSP inventory of workload in such a way as to require all MSP related claims be processed within 10 calendar days from the date in which the claim suspends will ensure the CMS requirement for the creation of “I” records is consistently met. When creating an NGHP MSP “I” record, not all diagnosis codes apply to No-Fault and Liability situations. A list of invalid/prohibited diagnosis codes can be found within the Section 111 NGHP User Guide on CMS.gov, Chapter V, Appendices I and J, at https://www.cms.gov/Medicare/Coordination- of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User- Guide/NGHP-User-Guide The A/B MAC transmits "I" records to CWF via the current HUSP transaction. The CWF treats the "I" validity indicator the same as a "Y" validity indicator when A/B MAC contractors process claims. "I" records shall only be submitted to CWF if no MSP record with the same MSP type already exists on CWF with an effective date within 45 calendar days of the effective date of the incoming "I" record. A/B MAC-created "I" records submitted to CWF that fail these edit criteria shall be rejected with an SP 20 error code. There are circumstances when an incomplete MSP claim is received and an A/B MAC shall not submit an “I” record. When this occurs the A/B MAC shall submit an ECRS Inquiry with all pertinent information found on the claim. It would be the responsibility of the MSP Contractor to establish the correct effective date. All A/B MACs shall submit an MSP Inquiry within ten (10) calendar days from the last day when the claim is suspended for MSP (internal system or CWF, whichever suspends first), or within 45 calendar days of receipt of the claim. If the ECRS attempt fails, the A/B MACs are reminded to resubmit the ECRS request within 48 hours, or two (2) business days. Follow up with your MSP Contractor consortia representative if the ECRS attempt continues to fail. Note: DME MACs do not submit “I” records to CWF. DME MACs instead utilize the ECRS process when the DME MAC receives a claim for payment, and the claim contains sufficient information to create an MSP record without further development. The MSP Contractor shall receive a trigger from the CWF when an “I” record is transmitted and applied. The MSP Contractor develops and confirms all "I" maintenance transactions established by the A/B MAC contractors. The MSP Contractor will delete an “I” record if: It has not received a response to its development request within 45 days; or it has determined that there is no MSP based upon the development response. An "I" record should never be established when the mandatory fields of information are not readily available to the A/B MAC and DME MAC on its claim or associated attachment (e.g., other payer’s explanation of benefits (EOB) paid or remittance advice). The following are to be used as default values when creating an “I” record: (1) MSP Effective Date: Use the Part A entitlement date for GHP. For NGHP use the date of incident as the MSP effective date as identified in the occurrence code field as found on the claim. (2) Patient Relationship: Use “01” if no indication of other insured member, and use “02” if another member is shown but uncertain of relationship. (3) MSP Type: For GHP, use the current reason for entitlement: working aged (12), disability (43), or ESRD (13). For NGHP, if not identified, the default to be used is No-Fault (14). In addition, a refund or returned check is no longer a justification for submission of an "I" record. Since an "I" record does not contain the source (name and address) of the entity that returned the funds, the MSP Contractor lacks the information necessary to develop to that source. Follow the examples below to determine which ECRS transaction to submit: 1. An MSP inquiry should be submitted when there is no existing or related GHP MSP record on the CWF and the incoming claim does not have enough information needed to create an “I” record. Note: A ‘related’ record means if an MSP record on CWF matches and has the same HICN/MBI, MSP type, MSP effective date, Insurance type, patient relationship code and, validity indicator. All A/B MACs shall submit an MSP Inquiry, or Assistance Request, within ten (10) calendar days from the last day when the claim is suspended for MSP (internal system or CWF, whichever suspends first), or within 45 calendar days of receipt of the claim. 2. The CWF assistance request should be submitted when the information on the CWF is incorrect or the MSP record has been deleted. 3. If the check or voluntary refund either opens or closes the MSP case or MSP issue. Under these circumstances, the A/B MAC or DME MAC shall submit an MSP inquiry to open or close the MSP record. The A/B MAC or DME MAC should refer to ECRS manual for more information regarding closed cases. The check should be deposited to unapplied cash until MSP Contractor makes an MSP determination. Refer to Chapter 6, Section 20.2 for examples. If the A/B MACs have the actual date that Medicare became secondary payer or the date of the accident or incident, it shall use that as the MSP effective date. If that information is not available, the A/B MACs shall use the Part A entitlement date as the MSP effective date. A/B MACs may add a termination date when creating an “I” record, if applicable. However, an A/B MAC cannot add a termination date to an already established "I" record in CWF. The following are mandatory fields for MSP records with a validity indicator of "Y" and "I": • Medicare beneficiary identifier; • MSP type; • Validity indicator; • MSP effective date; • A/B MAC identification number; • Insurer name; • Patient relationship; and • Insurance type. Chapter 6, §40.8, contains the CWF MSP utilization error codes, descriptions, and resolution for the A/B MAC’s use in correcting MSP utilization error codes.