ExamWorks Clinical Solutions’ Chronicle: Who is Medicare eligble?


ExamWorks Clinical Solutions welcomes you to our LinkedIn Chronicle. In these brief articles, we will cover the ins and outs of all things related to Medicare Secondary Payer, MMSEA Section 111 Reporting, and Case Management. Our articles will uncover basic concepts and then move through the many nuances involved, helping you navigate the oftentimes complicated regulations and processes. In addition, our subject matter experts will be addressing and sharing FAQs and lessons learned.

How do I know who is Medicare eligible?

MMSEA Section 111 Reporting starts with a single question; is the injured party Medicare eligible? Once you know if the injured party is or is not Medicare eligible, you can then determine your next steps. Before we cover how you determine the eligibility of an injured party, it is important to remember there are no safe harbors with Medicare. This means assuming eligibility based on age or any other assumptive measures will not suffice. Instead we must use the tools at hand to determine if an injured party is Medicare eligible. To determine Medicare eligibility, the Centers for Medicare & Medicaid Services (CMS) has provided Responsible Reporting Entities (RREs) with two different query methods. One is a manual query process found on the CMS website, and the other allows an RRE to submit a file electronically. For this article, we will focus on the latter of the two methods.

On a monthly basis, RREs are allowed to submit a single file electronically to CMS, and CMS will provide a query response file within 14 days. The file query file submitted to CMS contains what we like to call the “Big 5”. The “Big 5” consists of the injured party’s Social Security Number (SSN) or Medicare Beneficiary Identifier (MBI), First Name, Last Name, Date of Birth, and Gender. When CMS receives an RRE’s file, they compare the data provided to the data housed in their system. If the SSN and three of the remaining four fields (First Name, Last Name, DOB, & Gender) match what CMS has in their system, CMS will return a Yes indicating the injured party is Medicare eligible. If there is no match made or only a partial match (SSN/MBI and less than 3 of the Big 5), CMS will return an Undetermined. Undetermined means CMS was not able to match the data provided to an existing Medicare beneficiary.

As of January 2015, CMS allows RREs to complete the query process using the last 5 of the SSN. When using the last 5 of the SSN during the query process, CMS’ matching requirements are even more strict (last 5 of SSN AND the 4 remaining fields must match). The additional matching requirements increases the likelihood of receiving an Undetermined response. Moreover, using the last 5 of SSN for the Medicare query can result in a response indicating a duplicate match was made. In the event a Duplicate response is received, you will need to complete the query process again using the injured party’s full SSN. We strongly suggest using the full SSN for the query to ensure better accuracy.

It is important to note CMS will never return a definitive No in the query response file. If you receive an Undetermined response, it is important you verify the data you have on file and confirm it is the correct legal information for the injured party. CMS’ matching process only reviews the first initial of the First Name, and the first 6 characters of the Last Name. Submitting the query with the first name of Bill rather than the legal first name of William could result in an Undetermined Response from CMS. This inaccuracy in data submitted to CMS for query can potentially lead to non-compliance of MMSEA Section 111 Reporting.

MMSEA Section 111 Reporting is complex and requires coordination between claims operations, IT departments and executive leadership.  Substantial issues can arise if reporting falls short both internally (in the form of inefficiency and added cost) and externally (in the form of possible civil money penalties of up to $1,000 per day per claim).  If your organization is involved with claims having a medical component, whether directly responsible or not, you may be required to participate in MMSEA Section 111 Reporting.   If you have any questions about the reporting process or need assistance determining if you have an obligation to report, please contact us at MIRService.Support@examworks-cs.com.

Stay tuned for the next installment.