ECRS Functional Description

10.2.1 - ECRS Functional Description (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) In general, there are two ECRS submission processes: the MSP inquiry process and the CWF assistance request. The MSP inquiry process is used to transmit information to the MSP Contractor where no related MSP record exists on the CWF. The CWF assistance request is used to transmit information to the MSP Contractor to modify or delete existing MSP information currently residing on the CWF for any type of MSP situation. Assistance requests should be done only on “related” records (i.e., 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, same patient relationship code and, validity indicator is for the same insurer, and has part of or all of the MSP time span reflected on the claim. A/B MACs and DME MACs shall refer to the ECRS Web User Guide-Attachment 1 for step- by-step instructions on how to submit MSP inquiry and CWF assistance request transactions to the MSP Contractor, and how to perform status inquiries on previously submitted transactions. When entering the type of MSP record in ECRS, A/B MACs and DME MACs shall enter the correct MSP information even if the provider submits an incorrect MSP information including the insurer information found on the claim. Note, if information on a claim is received which necessitates the A/B MAC or DME MAC to create or update an MSP record in CWF, and the “I” record process cannot be used, an accurate MSP Inquiry or Assistance transactions shall be sent to the MSP Contractor within 10 calendar days from the last day the claim is suspended/rejected for MSP (internal system or CWF, whichever suspends first), or within 45 calendar days of receipt of claim. Invalid values will not be allowed in the following critical fields for any ECRS entries: HICN, MBI, MSP Type, MSP Effective Date, Patient Relationship and Insurer Name. Common Working File (CWF) Updates Allowed After “I” Record Development Period. However, A/B MACs shall not fax or email “I” record update requests to the MSP Contractor. Medicare A/B MACs shall only create an MSP Inquiry if the “I” record was deleted and they have confirmed other coverage. MSP Claims that Match Deleted “I” Records When A/B MACs receive claims with MSP payment information that conflicts with an already deleted “I” record created during the 45-day development period, they shall: 1. Remove the MSP payment information from the claim and pay the claim as primary; and 2. Apply Claim Adjustment Reason Code CO 45 or OA 23 with remittance advice remark Code MA 17 to the affected claims, or line items, as applicable. Additionally, A/B MACs and DME MACs shall submit an MSP Inquiry request when an “I” record was deleted during the 45-day development period only if one of the MSP matching criteria on the claim (MBI, MSP effective date, MSP type, Patient Relationship, or Insurer Type) is different from the existing MSP matching criteria on the deleted “I” record and there is not a matching “Y” validity record. If you receive information where the insurer information truly differs from what is found on the deleted “I” record (for example, BCBS and BCBSCA would be considered the same while BCBSCS and Aetna are truly different entities), submit an MSP Inquiry request. Invalid and Prohibited Diagnosis Codes Submitted on NGHP “I” Records. Not all diagnosis codes can be submitted on NGHP “I” record submissions. A list of invalid/prohibited diagnosis codes can be found within the Section 111 NGHP User Guide on CMS.gov at, 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. If the A/B MAC submits an "I" record with an invalid/prohibited diagnosis code, systematic development will still occur. If a response is received within the 45-day development period, the system will attempt to post a "Y" validity record in CWF. The record will be systematically reviewed by BCRS utilizing the normal edit process, which includes a review of the diagnosis codes. The system will flag the record with an SP22 error to allow for manual correction by the MSP Contractor before allowing the record to be posted to CWF with a "Y" validity. The below steps identify how the MSP Contractor handles the processing of the SP22 - Invalid Diagnosis Code for single and multiple diagnosis codes. • Scenario 1: A single diagnosis code is present on the MSP file and it is invalid/prohibited - The MSP Contractor rejects the record in full. The NGHP MSP record must have one diagnosis code on the MSP record. • Scenario 2: Multiple diagnosis codes are present on the MSP file, and the MSP Contractor locates invalid/prohibited code(s) - The MSP Contractors removes the invalid/prohibited code(s), but applies the MSP record to CWF (with at least one (1) diagnosis code being present). Updating Section 111 Records In the past A/B MACs and DME MACs have sent ECRS requests to the MSP Contractor requesting that GHP section 111 records be updated. The MSP Contractor has rejected most of these requests based on CMS hierarchy of Section 111 entities taking precedence in updating COB contractor number 11121 MSP records. However, CMS has clarified that the MSP Contractor shall accept A/B MACs and DME MACs ECRS requests to update Section 111 COB contractor number 11121 MSP records based on conditions below. A/B MACs and DME MACs shall continue to submit ECRS requests to the MSP Contractor for COB contractor numbers 11121 for the following circumstances: • When the A/B MACs and DME MACs receive information indicating the group number or policy number of the primary payer has changed; • When the A/B MACs and DME MACs learns of a retirement date for the beneficiary and a termination date must be added to the MSP record; • When the A/B MACs and DME MACs receive information indicating the Insurance Type A, J, or K has changed or conflicts with what is on the CWF MSP Auxiliary file; or • When the A/B MACs and DME MACs receive a primary payer EOB or remittance advice showing payment for a deleted or closed Section 111 GHP MSP record that should remain open. For COB contractor number 11122 MSP records, the MSP Contractor will not accept an NGHP record update request for any type of MSP claim situation. Note: For non-section 111 NGHP records the A/B MACs and DME MACs shall continue to submit ECRS requests to the MSP contractor for COB contractor numbers other than 11122, in order to make updates to the policy number, and add missing information. It is at the MSP Contractor’s discretion whether to approve the Section 111 ECRS requests upon review. Approval or denial of such ECRS requests shall be sent to the A/B MACs and DME MACs by the MSP Contractor. Those A/B MACs and the DME MACs that have questions regarding denial of ECRS requests shall contact their MSP Contractor consortia representative. ECRS Access: • A/B MACs and DME MACs that require access to ECRS Web must register in the CMS Individuals Authorized Access to CMS EIDM system to request ECRS access, and have a A/B MAC or DME MAC contractor ID and access code. If a MAC representative has an EIDM ID and password and an A/B MAC or DME MAC contractor number and needs assistance obtaining a A/B MAC or DME MAC access code, please contact the MSP Contractor. • To request an EIDM for access to ECRS WEB, A/B MACs and DME MACs should follow the directions provided in the latest ECRS Web User Guide; see section 10.2, Attachment 1, above, for a link to that Guide or reference section 5.1 of this chapter for the latest Guide update.) • MAC representatives should log back on to ECRS to check on the status of their request, including final determination.