WWW.REGTAP.INFO Vendor Management, Payments, and Collections (VMPC) Webinar March 30, 2020 Division of Financial Transfers and Operations (DFTO) This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable regulations for complete and current information about the requirements that apply to them.
Transcript
WWW.REGTAP.INFO
Vendor Management, Payments, and Collections (VMPC) Webinar
March 30, 2020Division of Financial Transfers and Operations
(DFTO)
This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable regulations for complete and current information about the requirements that apply to them.
• 45 CFR 156.430 sets forth regulations regarding CSR data submission and reconciliation– Under §156.410, QHP issuers must ensure that any individual
enrolled through the Exchange, who is eligible for CSRs,pays only the cost sharing required for the applicable covered service under the plan variation.
– In the case of improper assignment to a plan variation or impropercost sharing, the issuer must correct the plan variation assignmentand refund any excess cost sharing paid by the consumer. Issuerscannot submit as CSR provided any excess cost sharingprovided.
• For each BY, CMS reconciles CSR payments by collecting issuer data on what the enrollee in a CSR plan variation paid in cost sharing for the entire BY and what the enrollee would have paid in cost sharing with a standard plan. The difference is the amount of CSR provided.
• In October 2017, CMS announced that CSR payments will be discontinued until an appropriation exists. In the absence of an appropriation, CMS cannot make CSR reconciliation payments resulting from the BY 2019 data submission process and BY 2018 restatement process.
• CMS is providing an optional data submission window permitting issuers to submit CSR data for the 2019 benefit year and permitting restatements for the 2018 benefit year.
• To reconcile CSRs to reflect the amount provided to enrollees in CSR variation plans, issuers will submit their allowable essential health benefits (EHB) medical claims costs to CMS for the entire BY, broken down by:
– The amount the issuer paid,
– The amount the enrollee paid, and
– The amount the enrollee would have paid for the same claims if enrolled in a standard plan.
• For BY 2019 and BY 2018 Restatements, issuers must use the standard methodology to determine enrollee cost sharing amounts for comparable claims in the standard plan.
• Issuers must submit this data for each QHP plan for BY2019 and ifapplicable, separately for BY 2018 restatements.
April 6, 2020 Submission window opens, for all issuers, for BY 2019 data submission and BY 2018 restatements(NOTE: We will have webinars on April 6 and April 9, where we will give additional details).
May 29, 2020 Submission window closes for BY 2019data submission and BY 2018 restatements.
• Please submit your Payment Disputes!– Submit a Payment Dispute for any record perceived to be incorrect.– Issuers may submit large volumes of payment disputes without
impeding processing time.• Payment Dispute Support
– As a reminder, the FMCC team is the primary point of contact (POC) for resolving rejected payment disputes. Please reach out to the FMCC team at [email protected] with any questions regarding rejected payment disputes.
• CMS uses the Footnotes field in the RCNO file to provide additional information regarding the enrollment record and the results of reconciliation.
• An overall record flag of Q indicates that a matched record requires issuer action to resolve the data condition highlighted in the Footnotes field.
• The record may have one (1) or more fields flagged for issuer and/or FFE change; however, no FFE updates will be applied in this RCNO cycle due to the data condition.
• To resolve an overall record flag of Q, issuers need to either:– Update their internal records to reflect the FFE dates on the RCNO file.– Submit the appropriate dispute(s) to the ER&R Contractor to resolve the data
condition.• For example, a gap in coverage within a policy can only be created via the
Overall Record Flags of Q and Footnotes (continued)
• In records with an overall record flag of Q, the Footnotes field conveys the reason updates to data elements flagged for FFE update at the field level will be blocked.
• Q records will contain one (1) of the following footnote tags:– #GAP– #OVERLAP– #SPANSHORT– #NLE– #REJECTEDSPANCHANGE
NOTE: These footnotes will lead to persistent F field-level flags, which can cause problems with payments to issuers and incorrect 1095-A forms to be sent to consumers.
• For more information on footnotes and the overall record flag of Q, refer to the Enrollment Reconciliation Education Suite on zONE at https://zone.cms.gov/document/enrollment-reconciliation-and-ic834-workgroup-call-content.
NOTE: The #MERGE footnote tag does not require issuer action and will not cause an overall record flag of Q.
New Detail Code for Disputes on Records with an Overall Record Flag of Q
• PD646 and PY646 apply to disputes on records with an overall record flag of Q and a footnote indicating an issue that stops updates from occurring on that record.– PD646 Issuer Action: Review the Footnotes field for the disputed record
within the current RCNO file and take the appropriate action to correct the issue listed. If necessary, submit another dispute once the overall record flag of Q is resolved.
– PY646 Issuer Action: Review the most recent Pre-Audit file and submit the appropriate Enrollment Dispute.
• PD646 results in disposition code R6, Dispute Not Supported by RCNI.• PY646 results in disposition code R10, Dispute Not Supported by RCNI – Prior
New Informational Detail Code for a Disputed CSR Amount
• PY1406 is an informational code that applies to prior year disputes that identify multiple discrepancies, including the CSR amount, but no change will be made to the CSR amount.
• The presence of PY1406 will not impact processing of other values in the dispute. NOTE: PY1406 is similar to PY1401, which also indicates that the CSR amount will not be changed; however, these are different in that PY1401 is applied to disputes where the CSR is the only disputed value. – PY1406 Issuer Action: Review the other detail code(s) provided and take
the appropriate action.• PY1406 does not result in a disposition code. The disposition code will be
connected to the other detail code for the dispute.• Issuers can refer to the CMS page for more CSR guidance at
Modified Detail Code to Instruct Issuer to Review Pre-Audit Data
• PD530 and PD531 apply to disputes of missing or incorrect payments when the FFE is reporting the disputed record as cancelled and there is another record for the same member with overlapping coverage dates.
• PD530 and PD531 will continue to function the same way, but ER&R has modified the guidance provided to issuers.
• PD530 and PD531 modifications are as follows:– Previously, PD530 and PD531 advised issuers to review the RCNO file and take the
appropriate action on their next RCNI submission. – Going forward, PD530 and PD531 will advise issuers to review the policy in the most
recent Pre-Audit file before taking the appropriate action on their next RCNI submission.
• This change will prevent issues that occur when an issuer reviews their RCNO file after a new pre-audit file is distributed and before receiving the corresponding RCNO file.
• PD530 and PD531 result in disposition code R9, Mismatched Policy.
• Disputes for the 2019 coverage year are considered prior year disputes as of 04/01/2020. Account Manger (AM) approval for 2019 disputes will be required beginning on 05/01/2020.
• AM approval is not required for HICS Direct Disputes or prior year disputes that contain supporting HICS cases.
• Issuers must email a completed Issuer Prior Year Approval Request Form to their AM to request approval. The form is available on zONE at https://zone.cms.gov/system/files/documents/issuerprioryearapprovalrequest.xlsx.
• Upon receiving a confirmation email from ER&R, issuers should submit the approved prior year disputes before the due date provided.
• ER&R will return prior year disputes submitted after the AM-approved deadline with detail code FV110.
• ER&R will return prior year disputes that did not receive AM approval and do not contain a supporting HICS case with detail code FV111.
• ER&R continues to assign a large number of Payment Disputes an FV803 detail code, which results in the disposition code R8, Multiple Conflicting Disputes For Same Policy.
• Disputes are assigned the FV803 detail code when an issuer submits multiple disputes for a policy and the requested values in the disputes do not match.
• In order to avoid the FV803 detail code, issuers should:– Ensure there are no overlapping coverage dates between records
associated with the disputed record AND– Submit only one (1) dispute for a policy for any one (1) month OR– Ensure that all values within disputes for a given policy match
Following is an example of disputes that will receive FV803 detail codes:
• Conflicting fields that will result in an FV803 detail code include APTC Amount (issuer), CSR Amount (issuer), UF Amount (issuer), and Total Premium Amount (issuer).
• For more information regarding the FV803 detail code, issuers should review Section 5.5.3: Tips to Avoid Payment Dispute Error – Detail Code FV803 of the Combined Enrollment and Payment TRG on CMS zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation.
• ER&R is requesting that issuers email updated POC information to the ER&R Support Center.• Issuers may designate a primary and secondary POC.
NOTE: ER&R only sends notifications to the primary POC.• Issuers can update the POC by emailing the following information to
[email protected]:– Email subject: RECONCILIATION – ER&R CONTACTS– Issuer name– HIOS ID(s)– Trading Partner ID(s)– First name and last name of the POC– POC email address
NOTE: Issuers may provide multiple email addresses or a distribution list.– POC phone number
• Issuer POCs will receive the following: – Semi-Monthly Detailed Reports (ERRD and ERRZ) and UIR Reports (UIR#)– Proactive outreach to resolve disputes or when a high percentage of errors occur– Other unscheduled notifications related to ER&R disputes, UIRs, and ad hoc items
• Disposition and Detail Code List v26 is available on zONE. This version includes the new detail codes that were covered in this presentation.
• The Combined Enrollment and Payment TRG v9.0 contains minor updates and improvements.
• UIR TRG v9.0 and UIR Master Guidance v4.0 contain details regarding the new FFM_Updates_Pending category.
• The new Enrollment Dispute Training packet is now available on zONE. This packet contains a series of presentations, a video tutorial, and a quick reference guide designed to introduce new employees to the Enrollment Dispute process.
• Issuers can review the updated documentation on CMS zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation.
Step 1: CMS Secure Portal Registration Process:(Pre-requisite to CMSzONE Access)1. Register for access at CMS Secure Portal Here: https://portal.cms.gov/ 2. Click on “New User Registration” under CMSSecure Portal3. Complete information and create User ID and Password
Step 2: CMS zONE Access Request:1. Log in at https://portal.cms.gov/ with your CMS Secure Portal credentials 2. Click on “Request Access Now”3. Scroll down the page to find “zONE” and click on “Request Access” 4. Complete information and wait for confirmation email5. Once confirmation email is received, user may log-in to CMSzONE
Step 3: CMSzONE Private issuer Community Access:(After being granted CMS zONE access)1. Log into zONE; click on the Communities tab2. Click Browse Private Communities 3. Click Issuer Community – Private4. Click Join Community5. Provide explanation of why you need access to this community; Include:
• name and contact information• issuer POC contacts• specific work for issuer (i.e. fill out QHP templates, processing 834’s, etc.)
User Access Quick GuideA copy of the comprehensive User Access Quick Guide is posted on zONE @:https://zone.cms.gov/document/zone-end-user-access-quick-guide (pre-log in required to access zONE links)
Combined Enrollment and Payment Dispute Technical Reference Guide
• The Combined Enrollment and Payment Dispute Technical Reference Guide (TRG) provides guidelines for issuers regarding how to submit payment disputes.
• Issuers can access the TRG at the following links:– https://www.regtap.info/reg_librarye.php?i=2664– https://zone.cms.gov/system/files/documents/combined
The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary Categories, Benefit Year, Retired and Current FAQs, and Publish Date.
FAQ Database is available at https://www.regtap.info/
