Medicare Eligibility Submitters:

In a continued effort to improve database efficiency, in February 2007, the Centers for Medicare & Medicaid Services (CMS) purged Medicare beneficiary data from the eligibility database supporting the Medicare HIPAA Eligibility Transaction System (HETS) User Interface (UI) and HETS 270/271 – Extranet Transaction Submission system that is older than 27 months. Following, are examples of data purges that occurred:

• Part A and/or Part B entitlement periods with termination dates older than 27 months.

• Beneficiary records with a date of death greater than 27 months.

• Part B deductible information older than or equal to 3 years.

• Medicare Secondary Payer (MSP) records where other insurance coverage primary to Medicare has  a termination date greater than 27 months.

• Managed Care Organization (MCO) enrollment records that have a termination date greater than 27 months.

• Home health episode history data where the episode has an end date greater than 27 months.

• Hospice periods where the termination date is greater than 27 months.

• Hospital and Skilled Nursing Facility (SNF) billing data where the data used for calculating deductible and days remaining for the benefit period have a date of latest billing activity (DOLBA) date greater than 27 months.

• End Stage Renal Disease (ESRD) eligibility information with a termination date greater than 27 months.

Since eligibility information is designed to support the payment of claims, and the usual time limit for submitting claims is within 15 to 27 months of the date of service (depending on the month of service), the information source will be purged quarterly of all data older than 27 calendar months. Medicare regulations allow an exception to the timely filing requirements in cases of the Medicare program's administrative error. In the rare situation where eligibility information older than 27 months may be needed, Provider Contact Centers (PCCs) are available to assist providers or their representatives. The PCC representatives have access to the complete history of eligibility data from the source databases.

Effective 04/20/2007, to avoid misunderstandings and variations in responses, requests older than 27 calendar months will be rejected with the error 2100C AAA03 = 62 – Date of Service Not Within Allowable Inquiry Period. CMS will compare the requested date on the 270 to the calculated date; based on the date the transaction was received by the CMS system minus 27 calendar months, to determine the eligibility window. Until this change is made in April, Trading Partners should be aware that requests older than 27 months will produce unreliable data for the period beyond 27 months.

Examples of Acceptable Historical Query Date Ranges

Month Query Is Being Performed                  Begin Date Cannot Be Before:

                April 2007                                                   January 2005

                May 2007                                                    February 2005

                June 2007                                                    March 2005

                July 2007                                                    April 2005

Again, this is just one of many steps CMS is taking to improve the Medicare Eligibility transaction. You can share your comments or concerns with CMS by contacting the Help Desk.

Medicare Customer Assistance Re: Eligibility (MCARE) Help Desk: 1-866-324-7315

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Page Last Modified: 03/13/2008 11:08:06 AM
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