ERRP Focus

December 23, 2011

Reporting Bundled Claims: Bundled Claim Date Range

When reporting bundled claims, please remember that all claim detail lines submitted to substantiate the bundled claim detail line must have a From Date of Service and a To Date of Service that is within the date range specified in the bundled claim detail line. For more information on reporting bundled claims, review Illustration 6: Accurately reporting bundled claims in the Claim List in either the Secure Website Claim List Example Reference Guide or the Mainframe Claim List Example Reference Guide. In addition, visit Common Question 1100-23.

November 11, 2011

Claim List Total Number of Unique Retirees

The Claim List File Trailer Record field FT06 (Total Number of Unique Retirees) should only include individuals for whom Plan Sponsors are including claims in the Claim List. Although the Early Retiree List (ERL) requires you to include a Subscriber record on the ERL in addition to the associated Member record, this is not the case for the Claim List. For example, if a Plan Sponsor is including eligible claims for a Subscriber's dependent in the Claim List, the Plan Sponsor should only include the dependent in the Claim List's unique retiree count, not the Subscriber. It's important that the Plan Sponsor understands that there is a difference in how the retiree count is calculated for the Claim List versus how it's calculated for the ERL. The count is to reflect each individual (unique person), not the count of the different Member ID/Group ID combinations, as it may be possible for a person to have multiple Member ID/Group ID combinations based on enrollment in different plans.

November 11, 2011

Early Retiree List vs. Claim List Data

On July 18, the ERRP Center published Claim List Common Question H1100-21: "What fields in the Claim List must match fields within the Early Retiree List (ERL) to ensure claim data can be substantiated?" Those fields are the Application ID, Plan Year Start Date, Member ID, Member Group ID, Member Gender, and Member DOB. Plan Sponsors should note that the Member ID, which is defined as "The Plan's unique identification number for the Member associated with a given claim," is not the same as the Member Unique Person Identifier (UPI) found on the ERL. The UPI should not be submitted on the Claim List.

The following example demonstrates how the aforementioned six data elements are reported on the ERL and on the Claim List. Note how the ERL Member Unique Person Identifier and the Member ID are two distinct fields. In this example, the ERL Member Unique Person Identifier is the Subscriber's Social Security Number (111111111), and the ERL Member ID is a unique identifier which has been assigned by the plan (4443336661q). Claim List Member ID field HI02 is valued with the same plan-assigned identifier found in the ERL Member ID field (4443336661q), not the Subscriber's Social Security Number found in the ERL Member Unique Person Identifier field.

Early Retiree List (ERL) Fields

Application ID	Plan Year Start Date (CCYYMMDD)	Subscriber (Early Retiree) Social Security Number	Member Unique Person Identifier	Unique Person ID Type (1=SSN; 2=Alien ID; 3=I-94 ID; 4=Other Federal ID)	Member Birth Date (CCYYMMDD)	Member Gender (1=male; 2=female; 0=unknown)	Member Relationship to the Early Retiree (01=self; 02=spouse; 03=other)	Member ID	Member Group ID
1667500010	20100101	111111111	111111111	1	19500101	2	01	4443336661q	ABC Medical Plan

Claim List Fields

FH01 Type	FH02 Application ID	FH03 Plan Year Start Date	HI02 Member ID	HI03 Member Group ID	HI07 Member Date of Birth	HI08 Member Gender
DI	1667500010	20100101	4443336661q	ABC Medical Plan	19500101	2

November 11, 2011

Reporting Claim Adjustments

When reporting a claim that was adjusted, it is important to note that the ERRP Center requires that only the final total amount paid after the adjustment be reported. The claim detail lines included in the Claim List must contain the final adjusted amounts. Reporting the adjustment in multiple claim lines will adversely affect totals and potentially cause Claim List errors.

For example, if the original claim was reported to the ERRP Center with a Cost Paid by Plan Amount of $100, and the claim was adjusted at a later date for an additional $50 for a total Cost Paid by Plan of $150, the subsequent Claim List submission must include one claim line item for $150—not one claim line item for the original $100 and an additional claim line item for the total adjusted amount of $150. That would incorrectly total $250.00 instead of the expected $150.00.

October 1, 2011

Claim List Response File Layout

The Claim List Response File layout is now available on the Reference Materials page. The ERRP Center's automated review of a Clam List produces a Claim List Response File (CLRF). The CLRF indicates whether errors were found on the Claim List. If errors were found, the CLRF identifies the specific records with errors and the type of error(s) found. The CLRF layout provides the fields that are included in a CLRF and their associated properties. The CLRF Layout is the same for both CLRFs received via the ERRP Secure Website and via ERRP Mainframe, with the following exceptions: 1) the Start Position (Start Pos.) and the End Position (End Pos.) fields are only applicable to Mainframe CLRFs, and 2) the File Name size (Field No. 4) is 44 for Mainframe and 229 for Secure Website.

October 1, 2011

Claim List Response File Reason Codes

If your Claim List is not error-free, you will need to examine and correct the errors reported in the Claim List Response File (CLRF), by sending a corrected Claim List. The tool you will use to interpret the CLRF is the ERRP Claim List Response File Reason Codes document, which is found on the Reference Materials page. The ERRP CLRF Reason Codes document is an online reference tool for Claim List fields and their associated CLRF reason codes. CLRF reason codes correspond to a specific message about an error found in a Claim List record. Plan Sponsors are encouraged to review the detailed reason code document, especially the 'What It Means' and 'What You Should Do' information.

October 1, 2011

Claim List Response File Reference Guide

The Claim List Response File (CLRF) Reference Guide assists Plan Sponsors in identifying CLRF errors and reason codes to submit an error-free Claim List to the ERRP Center. The CLRF Reference Guide provides a CLRF overview, explains the CLRF layout, and discusses the Claim List field errors/reason codes.

October 1, 2011

ERRP Appeals Guidance

New ERRP guidance, Explanation of the Appeals Process for the Early Retiree Reinsurance Program, explains in detail the process for submitting a request for appeal of an adverse reimbursement determination. In addition, the guidance clarifies which types of adverse reimbursement determinations may be appealed.

October 1, 2011

New Reporting Data Inaccuracies and Reopening Guidance

The ERRP Center published Explanation of the Processes for Reporting Early Retiree and Claims Data Inaccuracies, and for Reopening on the Regulations and Guidance page. The guidance discusses the manner and timing for reporting and correcting previously submitted data inaccuracies. It also describes the process for instances when CMS reopens and revises a reimbursement determination on its own volition or upon request by the Plan Sponsor.

September 12, 2011

Claim List Revenue Code Field Updated

In the Claim List layouts, the following information has been added to the Description/Value column for Revenue Code (DI22): "A 4 byte code is strongly encouraged. However, if necessary, you may drop a leading zero (first character) and submit a 3 byte code. A code containing fewer than 3 bytes will cause an error."

September 12, 2011

Claim List Updates: Service Location Zip Code and Rendering Provider ID

The Claim List layouts have been updated with new information regarding Service Location Zip Code and Rendering Provider ID.

Service Location Zip Code

Plan Sponsors are required to provide either the Rendering provider's or the Billing provider's five digit United States zip code. If the Service Location Zip Code is not available, Plan Sponsors should submit the Rendering provider or Billing provider zip code. If neither of those are available, but the Plan Sponsor is certain the item or service was provided in the U.S., it should contact the ERRP Center. Review the Description/Value column in Claim List layout fields DP23, DI30, and DX23 for this updated information. If a Plan Sponsor is uncertain whether the item or service was provided in the United States, the Plan Sponsor should omit those claims from the Claim List since ERRP will not pay such claims.

Rendering Provider ID

Plan Sponsors must identify in the Claims List the provider that furnished the items or services for the claim as required under ERRP regulations. If the Plan Sponsor knows the Rendering Provider ID, that number should be submitted for the claims detail record. In instances where the Rendering Provider ID is not available, Plan Sponsors may submit the Billing Provider ID number of the provider or supplier that furnished that item or service. Review the Description/Value column in Claim List layout fields DP22, HI12, and HX11 for this updated information.

August 24, 2011

Secure Website Claim List Training Example

The ERRP Center has published a Secure Website Claim List Training Example to illustrate how to report data on the ERRP Claim List consistent with the ERRP Secure Website Claim List layout and the ERRP program requirements to attain an error-free Claim List submission. The SWS Claim List Training Example is presented using the Claim List Example Reference Guide, a detailed instructional document supported by realistic claim data. The Claim List Example Reference Guide provides detailed explanations of each Illustration and links to Illustration worksheets in a linked Excel workbook. The linked Excel workbook contains claim data worksheets to support each of the Illustrations discussed in the Reference Guide. The Claim List Example Reference Guide is now available on the Reference Materials page.

August 24, 2011

Secure Website Claim List Layout Updated

The ERRP Center removed the leading zeros from the decimal example in the description/value of the following fields: HP09, DP20, DP24, HI09, DI29, DI31, HX09, DX20, DX24, CA06, CB06, FT09, FT10, and FT11. The reason is because leading zeros are not required for Claim Lists submitted via the ERRP Secure Website.

August 5, 2011

Maintenance of Contribution Requirement

New program guidance, Guidance on Complying with the Prohibition on Using Early Retiree Reinsurance Program Reimbursements as General Revenue, is intended to assist Plan Sponsors in applying the maintenance of contribution requirement, while also helping to ensure that Plan Sponsors do not violate the prohibition against using ERRP reimbursement as general revenue. This and other ERRP guidance documents are found on the Regulations and Guidance page.

August 5, 2011

Claim List Quality Assurance Review

The ERRP Center is performing a quality assurance review of all Claim Lists to ensure that the data reported in the Claim List substantiates the data in the associated Summary Cost Data and reimbursement request. A Plan Sponsor should not submit a Claim List until it is reasonably confident that the Claim List is error-free. For more information, review the announcement Updates on ERRP Center Claim List Reviews, Enhancements to Educational Materials, and Upcoming Training Events.

August 5, 2011

Claim List Common Questions

The Claim List Common Questions relate to specific data fields within the Claim List Layouts and further clarify Claim List requirements. Monitor the Recent Changes section of the errp.gov homepage for future additions to the Claim List Common Questions.

August 5, 2011

ICD-9 Codes Ineligible for Reimbursement

The new guidance, Supplemental Guidance: Additional Coding Details for Ineligible Items and Services, further clarifies ERRP reimbursement policy by identifying certain International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes which are not acceptable as principal diagnosis codes and procedure codes which are not acceptable under Medicare. Both the guidance document and a corresponding CSV file containing the excluded codes can be found on the Regulations and Guidance page.

August 5, 2011

Updated Claim List Layouts

On July 18, the ERRP Center made important updates to the Claim List Layouts, including a reduction in the number of required fields. The field descriptions were also updated with new detailed information. In addition, links to Common Questions were added to some of the descriptions in order to further clarify certain field requirements. To locate updated information, review the highlighted areas in the Claim List Layouts found on the Reference Materials page.

August 5, 2011

Allocating Post-Point of Sale Price Concessions

New program guidance, Allocating Post-Point of Sale Negotiated Price Concessions to Individual Early Retirees Under the Early Retiree Reinsurance Program, is intended to assist Plan Sponsors in determining how much of a particular price concession should be allocated to a given early retiree. This and other ERRP guidance documents are found on the Regulations and Guidance page.