CMS Alert Regarding Upgrade of Query Files and HEW Software

On April 5, 2011, the Centers for Medicare & Medicaid Services (CMS) issued an alert providing information pertaining to the upgrade of Query Files and HIPPA Eligibility Wrapper (HEW) Software to ASC X12 270/271 Version 5010A1 under Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA). The alert addressed the implementation and scheduled upgrade to the Eligibility Inquiry/Response set used for Section 111 Query Files and the HEW translation software.

This upgrade affects all Section 111 query files exchanged with the CMS Coordination of Benefits Contractor (COBC). Differences between Versions 4010A1 and 5010A1 are minor and adoption of Version 5010A1 should not be difficult. The upgrade to the new version of HEW software (Version 3.0.0) should be completed by January 1, 2012 by all Responsible Reporting Entities (RREs) using the current HEW software. Testing of the new version is recommended but not required.

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PMSI Meets with CMS Regarding Prescription Drug Allocation Issues

On September 20, 2010, PMSI Settlement Solutions met with CMS to continue our dialogue around the pharmacy portion of MSA allocations. Our main focus during this meeting was to address inconsistencies we are all experiencing in the interpretation of the May 14, 2010 Memorandum regarding Part D covered prescription drugs. PMSI addressed inconsistencies concerning off-label prescription drug usage, the appropriate treatment duration for acute drugs, and the re-review process. For example, we highlighted inconsistencies across reviewers at the Workers’ Compensation Review Center (WCRC) regarding the exclusion of drugs like Lyrica, Gabapentin and Lidoderm. PMSI also requested that CMS issue a formal directive in regards to which compendia will be utilized during the review process. We highlighted the need for policies and procedures that would support the various policy memos.

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New Rated Age Policy Memorandum Released by CMS

New Rated Age Policy Memorandum Released by CMSOn June 8, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a policy memorandum regarding Rated Age (RA) language inclusion in Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) by submitters. The memo clarifies initial instructions regarding RA language outlined in a prior memorandum dated May 14, 2010, which required the following all-encompassing exact statement by submitters in regard to RAs:

“Our organization certifies that all rated ages obtained on the claimant, at any time during that individual claimant’s lifetime, have been included as part of this submission to the Centers for Medicare & Medicaid Services.”

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