Whether you are an RRE reporting claims to CMS directly or working with a reporting agent to report on your behalf, it is essential to understand the status of your claims and the results obtained. Most reporting agents understand how to transmit claims to CMS, but there are significant gaps in the industry amongst reporting agent strategies for CMS response files. Not understanding these differences could result in unnecessary work for your organization, frustrations in understanding your data, and substantial financial risk in the way of CMS fines. In the end, limiting risk is about successful submissions to CMS and understanding the responses CMS returns on claims. This analysis of the associated responses is crucial to understand the level of compliance an RRE seeks to achieve.
The NGHP User Guide provides an excellent start to understanding the possible responses for a claim reported to CMS. The first response code to be familiar with is the disposition code, which is identified as follows:
Every Claim Input File Detail Record will receive a disposition code on the corresponding Claim Response File Detail Record. Records rejected due to errors receive an ‘SP’ disposition code and must be resubmitted. Error-free records returned with an ‘01’, ‘02’ or ‘03’ disposition code because the injured party was identified as a Medicare beneficiary based upon the information submitted only need to be resubmitted under certain circumstances as specified below. Records with an injured party who was not identified as a Medicare beneficiary based upon the information submitted receive a ‘51’ disposition code. In rare cases, records that have not finished processing by the time the response file is generated will be returned with a disposition code of ‘50’ and these must be resubmitted on the next quarterly file submission.”
The good news is that for disposition codes 01, 02 and 03, as long as the data is correctly submitted and there are no subsequent changes, these claims are accepted by CMS and no other actions are likely required. However, compliance flags may be associated with 01 and 02 codes. Compliance flags will be addressed later this week in Part 2 of this post. For now, let’s examine disposition codes 01, 02 and 03:
- 01 Disposition Code: The record has been accepted for an individual identified as a Medicare beneficiary and the RRE has indicated they have ongoing responsibility for medicals (ORM). The claim does not need to be reported again unless ORM ends, a compliance flag was issued or if certain material fields have changed.
- 02 Disposition Code: The record has been accepted for an individual identified as a Medicare beneficiary and the RRE has indicated they have no ongoing responsibility for medicals (ORM). The claim does not need to be reported again unless a compliance flag was issued or certain material fields have changed.
- 03 Disposition Code: The record was matched to a Medicare beneficiary, but outside of the Medicare coverage period. The claim does not need to be reported as long as information was correctly submitted and there is no ORM (unless a TPOC is established at a later date).
Disposition code 50 indicates the COBC failed to process the claim in the stated 45-day turn-around timeframe. The user guide states that this should only occur in “rare circumstances.” PMSI’s experience suggests this has a going run-rate of somewhere between ¼ of 1% to ⅓ of 1%. The interesting thing about this disposition code is that it may not apply to all of the claims within a file. Some claims will get processed normally while other claims will be returned with the 50 code.
For disposition code 50, the records are neither in error nor accepted and must be resubmitted in the next quarterly file. This disposition code is not a reflection on the reporting agent, but the reporting agent must have a process to send the claims back to CMS in the next applicable reporting period. For this reason, these claims should not be counted in an acceptance or errors statistic, as the processing was simply halted by the COBC.
Disposition code 51 is a bit more complex, as CMS was unable to identify the injured party as a beneficiary when the claim was reported. This could be a surprise if the reporting agent is using the monthly query functionality to identify beneficiaries and received a positive match on the injured party. However, CMS stated on the May 4th, 2011 teleconference that this situation can occur, and indicated that a change to query logic at the end of 2010 could be responsible. The complexity of this situation increases, because again, the claim is not accepted by CMS and it is also not in error. These claims must be monitored for changes to TPOC payments, ORM status and beneficiary status, which may mean submitting the claim back through the query cycle once again.
For disposition code 51, our experience suggests that a run rate similar to that of disposition code 50 is the norm right now—about ¼ of 1%. For PMSI’s measurement, that is against beneficiaries determined through the standard query process. If the reporting agent has another methodology for determining beneficiary status, that number could be much different. If it is substantially higher, you may want to ask your agent about the query process they are utilizing. The primary reason for this question is about efficiency, as we believe you should focus on claims that need to be reported, not on claims for which CMS lacks interest.
PMSI has analyzed five out of six disposition codes, three of which are acceptances by CMS and two that are not acceptances, but are also not errors. The last disposition code, SP, is the code where CMS is advising a claim was not reported correctly. In Part 2 of this post, we will examine the SP disposition code in greater detail. If many SP codes are found on your claim file, chances are there are many error submissions in your file and the COBC might stop processing the file if certain thresholds are hit. We will take a look at why these errors are significant, and identify what questions to ask in reference to error rates to ensure a full understanding of how many claims are being rejected on each submission.