In compliance with Section 111 of the Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 (known as Section 111 of the MMSEA), CMS has implemented a process through which private insurers (both Group Health Plans (GHP) and Non Group Health Plans (NGHP)) submit coverage information to the Coordination of Benefits Contractor (COBC) when they also provide coverage to a Medicare beneficiary.
A private GHP insurer reporting under Section 111 is known as a Responsible Reporting Entity (RRE), and the COBC receives Section 111 data input files from approximately 1,500 GHP insurers, and each file can include large numbers of individual coverage records.
This information permits CMS to more accurately determine who (either the private insurer or Medicare) has primary, or secondary, claims coverage responsibility. Occasionally, information submitted to the COBC from any number of sources, including GHP RREs, service providers, and beneficiaries themselves can conflict with MSP information previously reported to the COBC.
To reduce such conflicts in the future, CMS has developed and implemented a data management “Reporting Hierarchy” process, which the COBC administers (effective April 1, 2011). An explanation of the Hierarchy rules can be found at http://www.cms.gov/MandatoryInsRep/Downloads/GHpHierarchy.pdf on the CMS website.
The COBC works closely with GHP RREs and other reporters in order to reduce “hierarchy” conflicts in future reporting. The following steps are in place to help providers update MSP records:
• Provider attempting update with the beneficiary in the office:
The first time a call is made to update the record after April 4, 2011, it will be updated via the telephone call. For any subsequent calls made to update the record after April 4 2011, no update will be made on the call, but two options are available:
1) Proof of information can be faxed or mailed on the insurer or employer’s company letterhead, and the update will be made in 10-15 business days; or
2) You can contact the insurer or employer organization that last updated the record.
• Provider attempting update when the beneficiary is not in the office:
No update will be made from a telephone call. The provider has 3 options to have the record updated:
1) Have the Beneficiary contact COBC;
2) Contact the Beneficiary’s insurer to resolve the issue; or
3) Fax or mail proof of information on the insurer or employer’s company letterhead and the update will be made in 10-15 business days.
• Provider with new information:
The COBC will take new information for a Beneficiary, but if the new information requires changes to an existing record, two options are available:
1) The Beneficiary will need to call to close out the record; or
2) Fax or mail proof of information on the insurer or employer’s company letterhead and the update will be made in 10-15 business days.
• Provider update for deceased beneficiary:
A SINGLE update can be made by ONE provider for a Deceased Beneficiary, once the date of death has been confirmed. Any subsequent updates would need to be handled by a family member with the appropriate documentation, including a death certificate.