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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.
July 27, 2020
FM Payment Processing 2020Risk Adjustment (RA): Payments, Invoicing, and Collections Process for the 2019 Benefit Year
Division of Financial Transfers and Operations (DFTO)
Session Guidelines
• This is a 90-minute webinar session • For questions regarding content, submit inquiries
to [email protected]• For questions regarding logistics and registration,
contact the Registrar at: (800) 257-9520
2
Agenda
• Risk Adjustment: Payments, Invoicing, and Collections Process for the 2019 Benefit Year
• Payment Dispute Guidance
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RA: Payments, Invoicing, and Collections Process for the 2019 Benefit Year
Overview
• Provide information regarding the payment, invoicing and collections process for the 2019 RA program including:– An overview of receiving payments (including High-Cost Risk Pool
(HCRP) payments) and a discussion of sequestration;– An overview of the Preliminary Payment Reports (PPR), HIX 820s and
Payee Information Reports (PNR);– An overview of the invoicing process; and– An overview on how to submit payments through Pay.gov
5
RA: Overview
• Section 1343 of the Patient Protection and Affordable Care Act (PPACA) established the permanent RA program
• On a permanent basis, non-grandfathered individual and small group market issuers of RA covered plans participate in RA
• For the 2019 benefit year, RA transfer reports and RA default charge reports (as applicable) were sent to issuers on July 17, 2020
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RA: Overview ( c o n t i n u e d )
• Beginning with the 2018 benefit year, the Centers for Medicare & Medicaid Services (CMS) implemented the HCRP component of RA
• HCRP payment reimburses issuers for 60% of issuers’ paid claims amount above $1 million for an enrollee
• For the 2019 benefit year, HCRP reports can be found on the issuer’s External Data Gathering Environment (EDGE) Management Consoles as of July 17th, 2020– HRPIPR (HCRP Issuer Payment Report)– HRPICR (HCRP Issuer Charge Report)
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RA: Overview ( c o n t i n u e d )
• Please note that the amounts set forth in the July 17, 2020 issuer reports available through the EDGE Server Management Console may not reflect amounts adjusted due to discrepancies
• If an adjustment occurs, CMS will notify you by email indicating whether the amount in the July 17, 2020 issuer reports was accurate or not
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RA: Timing of Charges and Payments
• In the August 2020 payment cycle, CMS will: – Net RA charges, RA default charges, RA user fee charges, or HCRP charges,
against any other payments being made in the August payment cycle, for issuers owing those charges
– After netting, send invoices to issuers of RA covered plans who owe remaining RA charges, RA default charges, RA user fee charges, or HCRP charges
• CMS will begin making RA payments in the September 2020 payment cycle and will continue as additional charges are collected in each state market risk pool
– No RA payments will be made in the August 2020 payment cycle • CMS will begin making HCRP payments in the November 2020 payment cycle
and will continue as additional HCRP charges are collected in each HCRP market
– No HCRP payments will be made in the August, September, or October 2020 payment cycles
*HCRP individual market includes the non-catastrophic, catastrophic and merged markets.
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September 2020 Payment Cycle: State RA Proration Begins
State RA Payment Proration• During the September 2020 payment cycle, CMS will begin making prorated RA payments for the 2019 benefit
year. CMS will distribute collected charges to issuers receiving payments based on the percentage of charges received when compared to the total outstanding charges for the state market risk pool (minus any sequestered amounts)
• Issuers will only receive payments if CMS has collected an RA charge or RA default charge in your state market risk pool
CMS will continue the monthly cycle of RA proration for each month RA charges are collected. CMS will notify issuers when we have fully collected all the charges for each state market risk pool or when CMS has exhausted all means to collect outstanding debts.• RA Proration Report (“RAPIR”) and RA Default Charge (RADC) Allocation Proration Report (“RADPIR”)
– Delivered when an RA or RADC proration payment is made– Made available on the issuer’s EDGE server management console– Reflects full prorated amount and final prorated amount including the amount of sequestration
withheld
Note: The RA Proration Reports have been updated for the 2019 benefit year. CMS will provide additional information in a future webinar.
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November 2020 HCRP Payment Cycle: HCRP Payment Proration Begins
• HCRP Payment Proration– During the November 2020 payment cycle, CMS will begin making prorated
HCRP payments for the 2019 benefit year. CMS will distribute collected HCRP charges to issuers receiving HCRP payments based on the percentage of HCRP charges received when compared to the total outstanding HCRP charges for the market (minus any sequestered amounts if applicable, and after netting)
• CMS will continue HCRP payment proration until all collected HCRP charges (after netting) have been released. CMS will notify issuers when we have fully collected all the HCRP charges for each HCRP market or when CMS has exhausted all means to collect outstanding HCRP debts
• HCRP Payment Issuer Proration Report (HRPIPR)– Delivered when a HCRP proration payment is made– Made available on the issuer’s EDGE server management console
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Payment and Collection Process: Overview
1. As discussed above, RA Program issuers received reports from CMS communicatingtheir RA payments or charges (including HCRP payment and charges) for the 2019 Benefit Year on July 17, 2020.• State RA payments and charges are calculated and invoiced by the issuer’s state
market risk pool, and invoiced at the payee ID level• HCRP payments and charges are calculated by issuer/market, and invoiced at the
payee ID level2. Payment Processing – Netting
• Each month, transactions (Account Payables [AP] and Account Receivables [AR]) for all financial programs are generally processed together
• ARs and APs are netted, resulting in a single transaction that is either a payment (Remittance Advice) or an amount owed communicated via an “Initial Invoice”
• Netting Order: RA > HCRP > RC > RI > APTC > CSR > RA UF, FFE UF
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Payment and Collection Process: Overview ( c o n t i n u e d )
3. After transactions are netted, payees who have a net positive amount will receive a payment from Treasury via Electronic Funds Transfer (EFT).• Payment may be reduced if there is a treasury offset for any balances
owed to the Federal Government outside of the amounts owed under the PPACA
4. After transactions are netted, payees who have a net negative balance will receive an initial invoice(s).
• Issuers will pay the invoiced amount at: https://www.pay.gov/public/home
5. Payment reports will be issued and sent via the normal PPR, HIX 820 and PNR process for Exchange issuers.• For non-Exchange issuers not set up to receive EFT files from CMS, the
Billing and Payment Contact (BPC) for the payee group will receive the PPR and PNR via email. Non-exchange issuers do not receive HIX 820s
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Payment and Collection Process:Netting
Payment and Collection Process: Holdback Overview
• For the 2014-2017 benefit years of RA, CMS held back a percentage of RA payments for sequestration and appeals until all RA appeals for a state market risk pool for the applicable benefit year were resolved
• Pursuant to guidance issued on May 31, 2019,* beginning with the 2018 benefit year and beyond, CMS will release the holdback amounts without regard to any pending appeals and make any necessary post-calculation adjustments in the event an appeal is successful
• Therefore, in the event of a successful state RA transfer, RADV, or HCRP appeal, CMS will make any necessary post-calculation adjustments to state RA transfers for the applicable benefit year in the impacted state market risk pools (or national market for HCRP)
– As a reminder, in light of the budget neutral nature of the RA program, adjustments made in the event of a successful appeal could result in additional charges being assessed or a decrease to payment amounts previously calculated to balance the state market risk pool (or national market for the HCRP)
*See https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Change-to-Risk-Adjustment-Holdback-Policy-for-the-2018-Benefit-Year-and-Beyond.pdf
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Payment and Collection Process: Holdback Overview ( c o n t i n u e d )
• However, RA payments will continue to be subject to sequestration
• The sequestration rate applied to RA payments made to issuers from fiscal year (FY) 2020 resources (that is, charges collected during the 2020 FY) is 5.9%
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Preliminary Payment Report (PPR), HIX 820 and Payee Information Report (PNR)
Timing of Reports for August 2020 Payment Cycle
For the August 2020 payment cycle, exchange issuers will receive a PPR, HIX 820, and PNR.
Key Payment ActivitiesInitial Invoice – sent to Issuers August 11-13
Preliminary Payment Reports (PPRs) and Payee Information Report (PNR) sent to issuers
August 14
Treasury issues payments to issuers August 20
HIX 820 sent to issuers August 30
Note: Non-Exchange issuers not set up to receive EFT files from CMS, the Billing and Payment Contact (BPC) for the payee record will receive the PPR and PNR viaemail. Non-Exchange issuers do not receive HIX 820s. Dates are subject to change.
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Timing of Reports for September 2020 Payment Cycle
For the September 2020 payment cycle, exchange issuers will receive a PPR, HIX 820, and PNR.
Key Payment ActivitiesInitial Invoice – sent to Issuers September 11-15
Preliminary Payment Reports (PPRs) and Payee Information Report (PNR) sent to issuers
September 15
Treasury issues payments to issuers September 22
HIX 820 sent to issuers September 30
Note: Non-Exchange issuers not set up to receive EFT files from CMS, the Billing and Payment Contact (BPC) for the payee record will receive the PPR and PNR viaemail. Non-Exchange issuers do not receive HIX 820s. Dates are subject to change.
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Timing of Reports for October 2020 Payment Cycle
For the October 2020 payment cycle, exchange issuers will receive a PPR, HIX 820, and PNR.
Key Payment ActivitiesInitial Invoice – sent to issuers October 9-14
Preliminary Payment Reports (PPRs) and Payee Information Report (PNR) sent to issuers
October 15
Treasury issues payments to issuers October 21
HIX 820 sent to issuers October 30Note: Non-Exchange issuers not set up to receive EFT files from CMS, the Billing and Payment Contact (BPC) for the payee record will receive the PPR and PNR viaemail. Non-Exchange issuers do not receive HIX 820s. Dates are subject to change.
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PPR Overview
• The PPR is a pipe delimited file, with function code I820, and contains all payment details and program level payment details for a payee
• The PPR and HIX 820 will contain a description of each transaction, if applicable, in the Document Control Number field
• If a payee is net negative in a payment cycle, the PPR will show a negative total payment amount
• PPRs will provide program level information for the RA program (including HCRP)
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HIX 820 Overview
• CMS uses the HIX 820 transaction to communicate payment information to payee groups or their designees
• The HIX 820, with function code F820, is sentseparately from the actual payment transfer
• CMS uses the HIX 820 to communicate remittance information for all financial management programs
• Exchange payees will receive one (1) HIX 820 a month per EFT• A payee will receive two (2) separate 820s and two (2) separate
EFT payments if the payee is set to receive a payment of $100 million or more
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PNR Details
• Transmitted to payees around same time of month as PPRs
• Generated at payee level for all programs and transmitted in pipe delimited format to the same EFT folder as other payment reports (i.e. PPR and HIX 820) with function code: PNR
• Provides issuers a snapshot of payee APs and ARs as of report run date and includes current payment cycle netting that occurred along with any outstanding AR balances as of the report run date
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PNR Transaction Details
• Includes all current payment cycle APs and ARs, similar to the data included on the PPR
• Provides details of any outstanding ARs, their original transaction amount, and amount prior to netting in the current payment cycle
• Shows the netting that occurred in the current payment cycle, payments made through EFT, and any remaining AR balance
• Report will be generated even if current cycle APs/ARs do not exist for payee, as long as payee has outstanding ARs
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PNR Program Information
The Program column of the PNR will display the same payment type codes that are found on the PPR and HIX 820. Please note the following exceptions and clarifications to this:
Program Type Code onPPR and HIX 820
Program on PNR
CSRN CSR
RAD RA
UFR, SHOPUF UF
Additionally, any Admin or Interest charges will appear as “ADM” for admin and “INT” for interest in the Program column of the PNR
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PPR, PNR, and HIX 820 File Issues
• Please follow the escalation path below for issues related to the transfer of the monthly PPR, PNR, and HIX 820 payment files:– Contact the CMS help desk and request a remedy ticket for the
issue. The help desk will assign the ticket to the appropriate support team who will reach out to issuers to resolve
– Email: [email protected]• See appendix for detailed payment type codes and
invoice number format
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Invoicing Overview
August 2020 Payment Cycle Timeline
Date EventAugust 13, 2020 Initial Invoice mailed if charges exceed payments
August 28, 2020 Deadline to submit Initial Invoice payments via Pay.gov
October 12, 2020Intent to Refer Letter transmitted if there is anoutstandingbalance
December 31, 2020Outstanding debt referred to the U.S. Department of theTreasury
The timeline above illustrates an example which assumes that the Initial Invoices are mailed on August 13, 2020.
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Timing of Invoice and Intent to ReferLetters
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• Initial invoices are emailed and mailed to issuers between the 10th and 13th of themonth if the total charges owed by the issuer exceeds payments due to the issuerin a given month‒ Initial invoices are generated by exchange and premium stabilization programs‒ CMS transmits separate initial invoices if amounts are owed for multiple exchange or
premium stabilization programs so issuers will receive an initial invoice for each program for which there is an outstanding balance
‒ Issuers must remit payments within15 calendar days of the date of the initial invoice • The Intent to Refer (ITR) letter will be sent 60 calendar days after the date of the
initial invoice if payment is not received by the initial invoice deadline• If no payment has been submitted 140 calendar days after the date of the initial
invoice, the debt will be referred to the U.S. Department of Treasury forcollection
Five (5)-Day Outreach
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• As a way to ensure that invoices have been received, CMS began making phone calls to issuers five (5)-days after an invoice is sent
• These are courtesy calls to confirm that issuers have received their invoice(s)
• CMS will be reaching out via phone to the Billing and Payment Contact (BPC) identified in the Vendor Management (VM) system
• If you have any questions about invoices, please email CMS at [email protected]
Failure to Submit Payment By Init ial Invoice Due Date
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• Any outstanding amounts owed to CMS and not paid within 15 calendar days from the date of the initial invoice will be assessed interest starting from the date of delinquency (i.e., 30 days from the date of the initial invoice and every 30 days thereafter)
• CMS updates the interest rate on a quarterly basis. The current CMS-established rate is 9.645%, effective April 2020
Intent to Refer Letter
ITR Letter Overview
33
• If payment is not submitted by the initial invoice deadline, an ITR letter is generated 60 days after the date of the initial invoice
• The ITR letter is the final request for payment before CMS refers the debt to Treasury and reflects administrative charges and accrued interest in addition to the original balance owed at the time
• If you want to make a payment, but you are unsure the balance owed, please email [email protected]
Failure to Submit Payment to Intent to Refer Letter
• Debts that remain unpaid 140 days from the date of the initial invoice will be referred to the Department of the Treasury
• Treasury will collect penalty charges and fees (including interest and administrative fees)
• Treasury will use all tools at its disposal to collect debt, including referral to the Department of Justice for litigation
• Contact the Treasury at (800)-304-3107 or visit the website at https://fiscal.treasury.gov/fscontact/fs_contact.htm
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Pay.gov
35
• Invoice and payments must be made electronically through Pay.gov
• Pay.gov is the portal to access the CMS Health Insurance Exchange and Premium Stabilization Programs Payment Form, which allows for the submission of payments for exchange-related and premium stabilization charges
• Access Pay.gov at https://pay.gov/public/home• For Pay.gov customer service, concerns, or technical issues
contact:‒ Call: (800) 624-1373 (Toll free, Option #2) or (216) 579-2112
(Option #2)‒ Email: [email protected]
Dispute Guidance
Payment Dispute Guidance
37
I. Payment Dispute RemindersII. Detail Codes Updates for FMCC Assistance III. Introduction to SEEDIV. Timing Issues in Payment DisputesV. New Detail Codes:
1. PD6262. PD656/PY656 and PD657/PY657
VI. Modified Detail Codes:1. PD553/PY553 and PD554/PY5542. PD633/PY633
VII. AM Approval of Prior Year DisputesVIII. Common Errors:
1. Avoiding PD5032. Avoiding FV8033. Avoiding FV9
IX. Enrollment Dispute Form v13X. zONE Publications
Payment Dispute Reminders
38
• 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
• Updated: Payment Dispute Support
– Please consult the detail code verbiage to identify the correct support team for assistance resolving rejected payment disputes. Use the contact information provided to submit any questions regarding rejected payment disputes
Detail Codes Updates for FMCC Assistance
39
• ER&R made updates to the verbiage of most of the Payment Dispute detail codes
• The only significant process change within these updates is that detail codes that previously instructed issuers to contact the Financial Management Coordination Center (FMCC) help desk now direct issuers to request assistance from one (1) of the following:
– ER&R Support Center– Recon Issuer Support– Exchange Service Desk
• Many codes also received cosmetic updates to clarify the instructions for an existing code or to make verbiage more uniform across multiple codes
• The updated verbiage is available in the published guidance documents on zONE
NOTE: ER&R also made similar changes to the enrollment dispute disposition code verbiage.
Reminder: Timing Issues in Payment Disputes
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• Timing issues occur when a dispute requests an update that was not present on the PPR but is included on the subsequent pre-audit file
• The PPR reports policies that will be paid for the current month or adjusted for retroactive coverage dates shown in the previous pre-audit file
• Issuers can submit payment disputes upon receipt of the PPR• About a week after the PPR, issuers receive the pre-audit file containing the policy
updates that will be included on the following month’s PPR and HIX 820– Submitting a dispute after verifying both the PPR and subsequent pre-audit file
against the issuer’s data ensures that the dispute uses the most current FFE data and minimizes timing issues
• The updates present on the pre-audit file will also be present on the RCNO file published later that month
• Payment disputes requesting updates that are present in the pre-audit file are considered timing issues
Reminder: Timing Issues in Payment Disputes ( c o n t . )
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• Issuers can avoid most timing issues by checking the pre-audit file to see if the issuer values are present in the FFE data before submitting payment disputes
• If the FFE updates in the pre-audit file align with the issuer’s enrollment and financial data, then the discrepancies present in the PPR are timing issues and it is not necessary to submit a payment dispute
• If discrepancies persist in the pre-audit file, then there are no pending corrections, and issuers need to follow the guidance provided in the Combined Enrollment and Payment TRG to submit a payment dispute or enrollment dispute to update the FFE values
• Examples of detail codes for timing issues include:
– C2 timing issue – update planned for next cycle• The updates in the payment dispute are found in the pre-audit file and the resolution will
appear in the next PPR
– C3 timing issue – update planned for later cycle• The updates in the payment dispute are found in the RCNO file and the resolution may not
appear in the next PPR, but is expected within two (2) payment cycles
New Detail Code for APTC Updates without a Valid Supporting HICS Case
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• PD626 applies to disputes that provide an updated APTC value, but do not reference a supporting HICS case
– PD626 Issuer Action: Identify a HICS case that contains the disputed APTC value and resubmit the dispute with the HICS ID. Alternately, the HICS case can be submitted to ER&R as a HICS direct dispute
• PD626 results in a disposition code R6, Dispute Not Supported By RCNI
New Detail Codes for Disputes Associated to Mult iple Coverage Years
43
• PD656/PY656 and PD657/PY657 apply to disputes erroneously submitted with a current year policy ID and coverage dates for a prior year
• PD656/PY656 will only apply to disputes associated to an Unaffiliated Issuer Enrollment (UIE), while PD657/PY657 will be used when the dispute is associated to a record containing FFM data
– PD656/PY656 Issuer Action: Issuers should identify the record on the UIR report and take the appropriate action to bring the record into alignment
– PD657/PY657 Issuer Action: Review the current pre-audit file, align the coverage dates in the dispute with the policy, and resubmit
• These codes are the inverse of PD553/PY553 and PD554/PY554, found on the next slide
• PD656 and PD657 result in disposition code R9, Mismatched Policy
• PY656 and PY657 result in disposition code R11, Mismatched Policy – Prior Year
Modified Detail Codes for Disputes Associated to Mult iple Coverage Years
44
• PD553/PY553 and PD554/PY554 codes still apply to disputes records containing a prior year policy ID and coverage dates for the current year (the inverse of PD656/PY656 and PD657/PY657, found on the previous slide)
• PD553/PY553 still apply to disputes on UIE records, and contain updated verbiage that refers issuers to the UIR report
– PD553/PY553 Issuer Action: Issuers should identify the record on the UIR report and take the appropriate action to bring the record into alignment
• Previously PD554/PY554 was only used for disputed records containing an overall record flag of L or R, but will now apply to all disputes on matched records that contain a prior year policy ID and coverage dates for the current year
– PD554/PY554 Issuer Action: Review the current pre-audit, align the coverage dates in the dispute with the policy, and resubmit
• PD553 and PD554 result in disposition code R9, Mismatched Policy• PY553 and PY554 result in disposition code R11, Mismatched Policy – Prior Year
Modified Detail Codes for Disputes without a Matching Policy
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• Previously PD633/PY633 would only apply to disputes associated to a UIE record, but will now apply to any dispute where ER&R was unable to find the disputed policy within the RCNO file using the identifying information provided in the dispute
NOTE: ER&R uses the values provided in the Policy ID, HIOS, and Subscriber fields of the dispute to identify the disputed policy.
– Issuer Action: Review the current pre-audit, and make the necessary corrections on the payment dispute form or subsequent RCNI submission
• PD633 results in disposition code R9, Mismatched Policy
• PY633 results in disposition code R11, Mismatched Policy – Prior Year
Common Errors: Avoiding PD503
46
• As of 01/01/2020, CMS changed the user fee rate for plans on the FFE from 3.5% to 3.0% and the user fee rate for plans on State-Based Exchanges that used the Federal Platform (SBE-FPs) was lowered from 3.0% to 2.5%
• ER&R received and rejected a number of payment disputes from issuers reporting incorrect user fees for 2020 policies
• The disputes requested user fee values based on the old 3.5% rate, but the current values correctly reflect the 3.0% rate
• These disputes received detail code PD503, which indicates a mismatch between the value included on the payment dispute and the RCNI file
Common Errors: Avoiding FV803
47
• 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
Common Errors: Avoiding FV803 ( c o n t . )
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• 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
Common Errors: Avoiding FV9
49
• ER&R has noticed an increase in the number of payment disputes receiving the FV9 detail code, which results in the disposition code R3: FFE Fields on Form do not Match PPR/HIX 820
• Disputes are assigned the FV9 detail code when an issuer disputes an unexpected or incorrect payment, but the PPR/HIX 820 report does not contain a record of a payment that matches the disputed data
• Most disputes that receive the FV9 detail code have the wrong payment cycle month on the dispute
• In order to avoid the FV9 detail code, issuers must ensure that the payment cycle month on the dispute matches the month in the Policy-Based Transition Payment Month field of the PPR and not the month that the coverage took place
Common Errors: Avoiding FV9 ( C o n t . )
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• Following is an example of a dispute that will receive an FV9 detail code:
• Other fields that can result in FV9 detail codes include:– HIOS ID– Exchange Assigned Policy ID– Coverage Period Start Date (FFM)– Coverage Period End Date (FFM)
Enrollment Dispute Form v13
51
• ER&R implemented the new Enrollment Dispute Form v13
• Enrollment Dispute Form v13 is available for download on zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation
• Issuers may also contact the ER&R Support Center at (855) 591-7113 or [email protected] to obtain a copy of the form
• ER&R will not accept enrollment disputes submitted on Enrollment Dispute Form v12
• The excel add-ins for Enrollment Dispute Form v12 are not compatible with v13. Issuers who use add-ins must install the v13-compatible add-ins to continue using them for v13
Enrollment Dispute Form v13 ( c o n t . )
52
• Improvements to the new version of the form include:
– Addition of Term Reason Code and Cancel Reason Code dispute types
– Addition of Term Reason Code and Cancel Reason Code fields to the Discrepancy Dispute tab
– Addition of the Cancel Reason Code values to the Rejected Enrollments tab
– Addition of the Term/Cancel Reason Code values and descriptions to the How to Guide tab
– FFM Internal Inventory Number is now optional for current year disputes as well as prior year disputes
– Changes to the examples and instructions to match the improvements listed above
zONE Publications
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• Disposition and Detail Code List v27 is available on zONE. This version includes the new detail codes that were covered in this presentation as well as verbiage that no longer references the FMCC help desk
• The Combined Enrollment and Payment TRG v10.0 contains updates related to the new disposition and detail code verbiage and recommendations on using SEED
• UIR TRG v10.0 and UIR Master Guidance v5.0 contain details regarding the new Add_Member_Enrollment_Blocker category and recommendations on using SEED
• Issuers can review the updated documentation on CMS zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation
Questions?
To submit or withdraw questions by phone: • Dial *# (star-pound) on your phone’s keypad
to ask a question.• Dial *# (star-pound) on your phone’s keypad
to withdraw your question.To submit questions by webinar:
• Type your question in the text box under the ‘Q&A’ tab.
54
Resources
RA Payment Type Codes
RA programs will use the following payment type codes on the PPR, PNR, and HIX 820
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RA Payment Type Codes (continued)
57
*RADV will not be used until early 2021
RA Payment Type Codes (continued)
58
These payment type codes along with all other payment type codes that appear on the PPR, PNR, and HIX 820 can be found on the Washington Publishing Company website: http://www.wpc-edi.com/reference/codelists/hix/payment-type-codes/
RA UF and RA Refunds Invoice Number Format
59
Position in Invoice Number Type Sample Value
1 Invoice Qualifier D, J, Q, or Z
2-3 Year 20
4-5 Month 08
6-12 (7 digit Payee) or6-13 (8 digit Payee)
Payee ID A000001 or A0000001
13-15 (7 digit Payee) or14-16 (8 digit Payee)
Transactional Seq Number 001
Example: RAUF Invoice number is D2008A000001001
RA, RAD, RADV*, and DDVC Invoice Number Format
Example: RA Invoice number is I19MD200812345001
Position in Invoice Number Type Sample Value
1 Market
I, L, T, M (RA) orN, O, H, B (RAD) or2, 3, 4, 5 (DDVC) or6, 7, 8, 9 (RADV)
2-3 Program Year 19
4-5 State Code MD
6-7 Year 208-9 Month 08
10-14 Issuer ID 12345
15-17 Transactional Seq Number 001
*RADV will not be used until early 2021
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HCRP and HCRP Refund Invoice Number Format
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Position in Invoice Number Type Sample Value
1 Market/Invoice Qualifier X, Y , or Z
2-3 Program Year 19
4-5 Year 20
6-7 Month 08
8-14 (7 digit Payee) or8-15 (8 digit Payee)
Payee ID A000001 or A0000001
15-16 (7 digit Payee) or16-17 (8 digit Payee)
Transactional Seq Number 01
Example: HCRP Invoice number is X192008A00000101
More Information on the PPR, HIX 820, and PNR
Presentations:– FMPPII: Invoice Overview, PBP Temporary Manual Adjustment & Payment Disputes
Updates (1/9/17) https://www.regtap.info/reg_librarye.php?i=1976– FMPPII: Invoice Overview, PBP Temporary Manual Adjustment & Payment Dispute
Updates (1/23/17) https://www.regtap.info/reg_librarye.php?i=1989– FMPPII: Invoice Overview, PBP Temporary Manual Adjustment and Payment Dispute
Updates (2/6/17) https://www.regtap.info/reg_librarye.php?i=2000– FMPPII: Transaction Details in the PPR & HIX820, PNR, Vendor Management &
Payment Disputes https://www.regtap.info/reg_librarye.php?i=2072– FMPPII: 2017 HIX 820s, Payment and Report Type Codes, VM, Restatement, SADP
Effectuation and Disputes https://www.regtap.info/reg_librarye.php?i=2128– FMPPII: 2017 HIX 820,Report, Premium Stabilization, 2016 Restatement, Vendor
Management, Dispute Info https://www.regtap.info/reg_librarye.php?i=2150– FMPPII: Reinsurance, Risk Adjustment and CSR Recon Overview, Reports, 2015-16
Restatement, Vendor Management, Closing 2014 Benefit Year, Invoicing and Dispute Information https://www.regtap.info/reg_librarye.php?i=2176
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More Information on the PPR, HIX, 820, and PNR ( c o n t i n u e d )
Supporting Documents:– FFM Preliminary Payment Report Schema (2/6/17)
https://www.regtap.info/reg_librarye.php?i=1282– State Based Marketplace (SBM) Preliminary Payment Report
Schema (2/6/17) https://www.regtap.info/reg_librarye.php?i=1994– Sample PNR (Excel Format)
https://www.regtap.info/reg_librarye.php?i=2107
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Financial Management Coordination Center
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• The FMCC help desk at [email protected] assists issuers with:‒ Questions or concerns regarding the Payment Dispute process‒ Technical assistance‒ File submission
• When contacting the FMCC, issuers should include their five (5) - digit HIOS ID and their seven or eight - character payee ID, along with their request
Resources
Resource Resource Link
Centers for Medicare & Medicaid Services (CMS)
http://www.cms.gov/
U.S. Department of Health & Human Services (HHS)
http://www.hhs.gov/
The Center for Consumer Information & Insurance Oversight (CCIIO) web page
http://www.cms.gov/cciio
Consumer website on Health Reform http://www.healthcare.gov/
Pay.gov Web Help https://www.pay.gov/WebHelp/HTML/about.html
Registration for Technical Assistance Portal (REGTAP) - presentations, FAQs
https://www.REGTAP.info
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Inquiry Tracking and Management System (ITMS)
Stakeholders can submit inquiries to https://www.REGTAP.info through ITMS.
Select “Submit an Inquiry” or to view submitted inquiries select ‘My Inquiries’ from My Dashboard.
Note: Enter only one (1) question per submission.
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FAQ Database on REGTAP
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.
FAQs Database is available at www.REGTAP.info
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Closing Remarks
