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CMS Releases Alert for Changes to Response File Naming Convention

By , October 28, 2014 8:45 am

CMS has released an alert dated October 27, 2014 detailing changes to the naming convention for claim, TIN and query response files that will take effect April 6, 2015. In order to ensure that filenames remain unique, CMS is modifying the time, or “T,” node of the filename convention. Instead of four digits representing seconds and centiseconds, a number from 0000 to 9999 will be inserted in the filename.

CMS had recently enabled this change in their production systems and it was detected by the Helios Section 111 reporting platform, MedicareConnect. After Helios brought the matter to CMS’s attention, and reminding them that the response file specification was published in the User Guide, CMS agreed to revert back to the previous coding and publish an alert to provide the normal six months of advance notice.

The full alert can be found at the following address:

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect at


CMS Withdraws Rulemaking on MSP and Future Medicals

By , October 16, 2014 3:41 pm

We previously posted blogs regarding CMS working on a proposed rulemaking regarding Medicare Secondary Payer requirements and future medicals. Our initial blog with more information on this ANPRM can be found here. Our secondary blog which indicated that CMS was looking to move to the NPRM stage of the rulemaking can be found here.

CMS never did resume rulemaking last year in September as was previously indicated by CMS on their regulatory calendar. Instead, CMS took no noticeable action on the rulemaking until October 8, 2014 where they withdrew the rulemaking altogether. Notice of the withdrawal can be found here:

Within the rulemaking, CMS was considering providing various options pertaining to protecting Medicare’s interests with regard to future medicals in both workers’ compensation and liability cases. The most well known part of the rulemaking was around allocations in liability cases, as this would be the first official guidance published/provided by CMS with regard to allocations in liability cases, also known as liability MSAs (LMSAs).

So where does this leave us all with regard to allocations in liability cases, now that CMS has withdrawn the rulemaking? Although CMS has, for the moment, chosen not to clarify when and how parties can take Medicare’s future interests into account in liability cases, the Medicare Secondary Payer laws (MSP) still mandates that Medicare remain the secondary payer, both pre-settlement as well as post-settlement.

Additionally, there has been speculation in the industry that this is not the last we will see of this rulemaking, and that CMS plans to later re-draft and re-file the proposed regulations. It is unclear if and when this will happen, as CMS has silently withdrawn this rulemaking with no public comment. Therefore, the industry should expect that this rulemaking will eventually resurface.

While many have applauded the withdrawal of this rulemaking, an argument could be made that there would have been some benefit to finalizing the rulemaking. Perhaps it would have brought some certainty within the liability industry regarding when and how Medicare expects its future interests to be taken into account in liability cases.

There has continued to be ongoing confusion as to when and how to take Medicare’s interests need to be taken into consideration with regard to the future medical component of these claims due to the lack of guidance from CMS. We have seen this demonstrated in various case law across the country where courts have issued divergent opinions on whether LMSAs are required under the MSP.

Hearing from CMS on this issue would have provided some solidarity on this contentious issue so that liability settlements with Medicare beneficiaries could occur and the parties could have confidence that their settlement has complied with Medicare’s interests.

Helios will keep subscribers updated on any additional developments on this issue and forthcoming rulemakings.


CMS Releases Updated NGHP User Guide Version 4.3

By , October 8, 2014 10:58 am

CMS has released an updated User Guide for NGHPs, version 4.3, on October 6, 2014.

While the updates contained in the new version appear to be minor, Helios encourages RREs and claim administrators to review the new User Guide in its entirety to ensure compliance. The changes are noted in the revision history of the document as the following items:


  • CR12120: When implemented, RREs will not be allowed to report ICD-10 “Z” codes. These are now excluded from Section 111 claim reports(Chapters IV & V).
  • CR 12178: Missing excluded ICD-10 codes added to Appendix J, Chapter V.
  • CR 12373: Updated to reflect the delay of ICD-10 diagnosis code implementation from October 2014 to 2015 (Chapters IV & V).
  • CR 12590: For ICD-10 changes, field numbering/layout discrepancies were corrected in Table A-2 (Claim Input File  Supplementary Information), Chapter V.
  • CR 12170: Two threshold error checks for the Claim Input File were implemented in July 2011. These errors are related to the dollar values reported for both the cumulative TPOC amounts and the No-Fault Insurance Limit (Chapter IV).
  • CR 12593: Reviewed to ensure that spouse references are gender-neutral according to DOMA.
  • CR 12636: The Appendix L alerts table has been removed and replaced with links to the Section 111 web site, which posts all current alerts and stores all archived alerts (Chapter V).
  • CR 12829: Updated CS field numbers in Table F-4 (Claim Response File Error Code Resolution Table) to accommodate ICD-10 revisions(Chapter V).

Details of each noted change request are located in the first chapter of each section of the guide.

The updated chapters of the User Guide 4.3 can be found at the following address:

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect at


WCMSAP Now Allowing Users to Directly Input Prescription Drug Information

By , October 7, 2014 10:04 am

As of yesterday, October 6, 2014, users of the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) can now directly input prescription drug information and calculate the proposed prescription drug portion of a WCMSA proposal. Please see our prior blogs for more information on this release: our blog discussing the initial alert issued by CMS announcing this functionality can be found here, and our secondary blog which links to and discusses a subsequent presentation issued by CMS explaining this functionality can be found here.

Our initial impressions of this functionality show that users must input case information on a claimant/case prior to be able to look up the prescription drug pricing. In other words, users cannot just look up a drug without providing corresponding case information first. This new functionality is going to be extremely helpful and eliminate discrepancies from AWP differences.  We are very pleased that this functionality is now available.


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