News and Events

The Centers for Medicare & Medicaid Services (CMS) is announcing several important changes that will improve and streamline the process of submitting claims data for ERRP reimbursement requests. A new, fully-automated review system will give detailed feedback on Claims Lists, helping plan sponsors submit error free Claim Lists starting October 3. CMS is also introducing new flexibility in the permitted layouts for Claims Lists, and CMS has extended the deadline for submitting detailed Claims Lists for prior reimbursements. These changes will simplify the experience for plan sponsors submitting Claim Lists to CMS while helping to improve the integrity of the ERRP program.

On Monday, October 3, 2011, CMS will begin providing specific, claim line-level feedback to sponsors who submit Claim Lists through a new, fully automated review system. Given this expedited feedback, all Claim Lists submitted on or after October 3 must be error-free in order for the plan sponsor to be able to submit a reimbursement request, and then be approved for payment. If a Claim List is determined to be invalid as a result of the automated review and cancelled from the system, the sponsor may resubmit a corrected Claim List. Similarly, before the automated processing system becomes effective in October 2011, Claim Lists and reimbursement requests that have errors will be cancelled from the system, and plan sponsors may resubmit them.

To provide plan sponsors with sufficient time to prepare for this level of review, the deadline for plan sponsors to submit error-free Claim Lists in support of reimbursements received based on a summary of aggregated claims has been extended from December 31, 2011 to March 30, 2012. Starting on October 3, for a Claim List to be deemed error-free, it must pass the automated review.

Finally, CMS is granting sponsors additional flexibility in submitting detailed claims information, offering options on some elements while maintaining fiscal integrity. Plan sponsors should refer to the updated Claim List layouts provided on www.errp.gov for guidance on how to supply required data, and to the questions and answers provided below.

If you have questions or need additional information, please contact the ERRP Center.

Below are answers to some specific common questions that plan sponsors and other interested parties have recently asked about Claim List submission.

Plan sponsors and their vendors may not always know the zip code of the provider who rendered a medical item or service. What options do plan sponsors have to provide this information in their Claims List?

To ensure program integrity, plan sponsors provide either the rendering provider's or the billing provider’s five digit U. S. zip code.

If a plan sponsor cannot provide the zip code of the rendering or billing provider, but is certain that the item or service was provided in the United States, the sponsor should contact the ERRP Center to discuss alternative means of documenting the location of the provider or supplier for the claim(s) in question.

If a plan sponsor is uncertain as to 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.

Plan sponsors and their vendors may not always know the rendering Provider Identification number (Provider ID). Will ERRP accept the identification number of the billing provider?

Plan sponsors must identify in the Claim 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 instead.

Can a plan sponsor pro-rate the overall amount of a bundled claim payment to each line of service detail on the claim associated with such a payment?

When multiple items or services are provided and paid under one bundled payment, plan sponsors should submit a Claim List that includes the amount of the bundled payment, and separately identify all items and services associated with such a payment. As an alternative, when submitting such claims, plan sponsors may "unbundle" the overall amount of the bundled payment by pro-rating the bundled payment to each of the items and/or services associated with such a payment. Any plan sponsor that uses a pro-rating approach must be prepared to provide its methodology upon request.

If any of the detailed claim lines associated with a bundled payment includes a procedure or diagnosis code that is ineligible for ERRP reimbursement, the entire Claims List will be rejected. Plan sponsors should therefore omit any ineligible codes and the associated prorated amounts from Claim Lists.

Will a Claim List be rejected because it includes invalid data in an optional field?

The ERRP Center will not reject a detailed Claim List for correctly formatted data included in "optional" fields unless the optional data include secondary procedure or diagnosis codes that are ineligible for ERRP reimbursement. Information provided in "optional" fields may be subsequently reviewed in any post-payment audit and program integrity efforts.

Sponsors should note that, if data are present in an "optional" field, then the data will be checked for format. For example, if the "optional" field is defined as numeric, any data provided in that field must be numeric. Similarly, data in an "optional" field may not exceed the maximum field length, as defined in the applicable Claim List layout.

In reviewing and processing Claim Lists and new reimbursement requests, will ERRP apply a tolerance threshold or other "safe harbor" to allow for a specified number of data errors that may inadvertently be included by plan sponsors?

Claim Lists and reimbursement requests cannot include any data errors or anomalies. The ERRP automated claims processing system update, available in October 2011, will provide sponsors with specific, expedited information on data errors inadvertently included in their submissions, so that sponsors can make all necessary corrections prior to requesting reimbursement. This feedback will be provided in a detailed response file within five business days. The response file will identify specific errors in the Claim List, including the location of any errors. We encourage the plan sponsor to address all of the identified errors and resubmit a corrected Claim List. The plan sponsor will not be able to submit summary cost data to request ERRP reimbursement until the detailed Claim List is error-free.

When submitting reimbursement requests, plan sponsors should note that the summary cost data amounts entered in the ERRP secure website have to reconcile with the amounts included in the Claim List trailer record. Starting in October, plan sponsors will be notified immediately in the ERRP secure website if their Claim List trailer data do not reconcile with their summary cost data entered in the ERRP secure website. This will allow sponsors to immediately review their submissions and fix any cost inconsistencies.