Clarification on Termination of the Incoming Claim Health Insurance Portability and Accountability Act (HIPAA) Contingency for RHHI
The Centers for Medicare & Medicaid Services (CMS) has received a number of inquiries about the impact of termination of the contingency plan for incoming claims on October 1, 2005, on submission of Medicare Secondary Payer (MSP) claims. The following information is being furnished to clarify the Medicare requirements for submission of compliant MSP claims as required by the Health Insurance Portability and Accountability Act (HIPAA).
On August 4, 2005, CMS announced that the HIPAA contingency period for claims sent to Medicare would end on October 1, 2005. This termination does not apply to claims that Medicare sends outbound to other payers that have signed a coordination of benefits (COB) trading partner agreement for the transfer of claims by Medicare. It does apply to claims sent to Medicare for secondary payment following processing by a primary payer, however. Therefore, effective October 1, 2005, electronic MSP claims must comply with all X12 837 version 4010A1 implementation guide requirements, and include standard claim adjustment reason (CAS) codes to describe adjustments that a primary payer made during adjudication, or they will be rejected.
CMS is aware of provider concerns that primary payers frequently send paper explanations of benefits or 835 transactions that contain local messages or codes rather than standard CAS codes. HIPAA does not require that standard CAS codes be reported in paper explanations of benefits, and payers that still have an X12 835 HIPAA contingency plan in effect may not yet be able to report standard CAS codes. HIPAA does require health care benefit payers to send providers X12 835 version 4010A1 transactions if requested by providers, and those 835 transactions must contain standard CAS codes by the end of each payer's 835 contingency period.
CMS is working with the HIPAA standards committee that maintains the CAS codes to develop a simplified means to translate non-standard messages and codes into standard CAS codes. We expect this process to be approved and implemented quickly. However, until an alternate solution is approved for use, electronic MSP claims sent to Medicare are required to contain standard CAS codes, along with other loops, segments, and data elements that apply. It is the provider's responsibility to convert local adjustment reason codes or messages into the appropriate standard CAS codes prior to transmission of an 837 version 4010A1 claim to Medicare for secondary payment.