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Centers for Medicare and Medicaid Services (CMS) is moving toward Civil Money Penalties for improper reporting

December 7, 2020 · Lavonya Chapman, Esq, RN, CMSP, Associate General Counsel, Optum Settlement Solutions

On November 12, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Technical Alert and published version 6.1 of the Non-Group Health Plan (NGHP) Section 111 User Guide. Both note changes that will eventually impact Civil Money Penalties (CMP) involving Section 111 reporting when CMS error tolerance thresholds are exceeded.

The technical alert and user guide revision are an early holiday gift from CMS to clarify data validation errors and reclassify some as “soft errors.” “Soft errors” do not involve data elements that materially impact the data reported in the Section 111 Claim Input File. As such, the information can still be processed, accepted, and not rejected. CMS alerts RREs of the “soft errors,” which should be corrected by the RRE on their next quarterly file submission.

Unlike the “soft errors,” required data elements submitted as incomplete or incorrect will be included in the RRE’s error tolerance threshold calculation when CMPs are imposed. 

Section 111 Data Flow between RRE and CMS

With this update, as of April 25, 2021, several Section 111 Claim Input File errors that would have previously caused a Claim Response File to be rejected will now become “soft errors.”

Most of the “soft error” codes pertain to optional claimant information (e.g., phone number, representative contact information) and formatting errors. The new “soft errors” will not result in the rejection of a record but should be corrected by the RRE on the next quarterly file submission.  (Refer to Section 111 NGHP User Guide v6.1, Ch. 5, Appendix F and table F-30 for each disposition, error, and compliance flags details and descriptions).

Error Code Descriptions are prefaced with two letters followed by two numbers.

  • Error codes that begin with a “C” indicate that the error occurred in the Claim Input File.
  • Error codes that begin with a “T” indicate that the error occurred in the TIN Reference File.

The following table separates the prefaces of the error codes with a description to what to the matter relates:

Soft Error Codes returned in  Claim Response File
CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP03, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30

Error Codes beginning with Relate to
CB Claim Beneficiary Information
CC Claim Claimant Information
CI Claim Injury Information
CJ Claim Ongoing Responsibility for Medicals (ORM) or Total Payment Obligation to Claimant (TPOC) Information 
CP Claim Plan Information
CR Claim Representative Information
CS Claim Self-Insurance Information
CT Claim Auxiliary TPOC Information
SP Errors returned by CWF
TN TfN Reference File Errors

New Error Code CP13

In addition, a new “soft error” code, CP13, will be added to the Section 111 Claim Response File processed by CMS. The CP13 error indicates that the No-Fault insurance limit submitted via a Section 111 Claim Input File is less than $1,000. While the record will be accepted by CMS, the CP13 soft error must be corrected by the RRE on the Claim Response File before the next quarterly submission date. CMS has been monitoring this for several months which likely prompted the new CP 13 error code which also should be corrected and resubmitted on the RRE’s next quarterly file submission.

Refer to the Section 111 NGHP User Guide, v6.1, Ch. V, Appendix F (pp F-40) for a description and detail of the new CP13 Error Code. 

A CP 13 error code will be returned on the Claim Response File when the
No-Fault Insurance Limit
(Field 61) is less than $1,000.

  • The RRE must specify dollars and cents with an implied decimal.
  • There is no formatting
    • No $ or , or .
    • The last two positions reflect cents
      Examples:
      $10,500.00 should be coded as 00001050000 
      $500.00 should be coded as 00000050000

Disposition Codes                 

When CMS’ Benefits Coordination and Recovery Center (BCRC) receives the Claim Input File from the RRE, CMS processes it and responds by returning the Claim Response File to the RRE. The Reporting Agent/File Submitter should monitor and forward to the RRE each disposition, error, “soft error”, and compliance code(s) returned from CMS.

Claim Response File Dispensation Code Indicates…
01 The data in the Claim Input File has been accepted by the BCRC and the RRE has indicated ongoing responsibility for medicals (ORM)
02 The Claim Input File was accepted by the BCRC, but the RRE had no ORM indicated.
03 The data processed was found to be error-free, the claimant was matched to a Medicare beneficiary, but the beneficiary was not Medicare entitled during the quarterly reporting cycle.
50 The Claim Input File is still being processed by CMS and must therefore be resubmitted on the next quarterly file submission.
51 The claimant did not match as a Medicare beneficiary.
SP Immediate action is needed since the SP disposition codes means that CMS did not accept the Claim Input File because of data errors reported. NOTE: When over 20% of an RRE’s Claim Response File is returned by CMS with an “SP code, the percentage of errors has exceeded CMS’ error tolerance threshold. (Refer to Section 111 NGHP User Guide, v6.1, Ch. V, Appendix F Table F-1)

Tiered Approach to Imposing CMP

As previously mentioned, CMS announced its intent to impose Civil Money Penalties (CMP) against RREs who fail to properly report via Section 111 reporting. One of three areas in which CMS proposes that CMPs be imposed is when the RRE Claim Response File exceeds error tolerance threshold in any four of eight consecutive reporting periods.

To calculate the CMPs, CMS proposes a tiered approach. If the RRE exceeds the error tolerance threshold in their fourth consecutive quarterly submission, the penalty would be applied using a “sliding scale” of 25% to 100% based on the number of calendar days that the RRE exceeded the error threshold tolerance in the RRE’s fourth Section 111 submission. For more information on proposed CMP calculations, refer to (https://www.govinfo.gov/content/pkg/FR-2020-02-18/pdf/2020-03069.pdf).

Conclusion

The Claim Response File “soft error” codes will reduce the frequency of Section 111 data processing “errors,” and reduce the time Medicare takes to process the Claim Input File and return the Claim Response File with or without error codes.

  • Optum encourages RREs to review all errors, disposition, compliance codes promptly and make corrections by the next quarterly reporting period.
  • For CMS no-fault claims (Premises med pay, auto med pay, and auto personal injury protection (PIP) coverage), the ORM indicator should be turned to “yes” and policy limits must reflect the correct dollar amount (combine both auto PIP and med pay if applicable)
  • The policy limit amount must be above $1,000 to avoid the new error code CP13

Optum will continue to closely watch any Section 111 reporting alerts and changes. Contact Lavonya Chapman at lavonya.chapman@optum.com to learn more about how these changes may impact your claims Section 111 reporting. 


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