FM Series V: Manual Workbook Submission, May & June ...
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FM Series V: Manual Workbook Submissions, May & June Payment Cycles, May Policy-based Payment Transition, and Dispute Updates May 16, 2016 Financial Management Series V HTTPS://WWW.REGTAP.INFO
Transcript of FM Series V: Manual Workbook Submission, May & June ...
FM Series V: Manual Workbook Submissions, May & June Payment Cycles, May Policy-based Payment
Transition, and Dispute Updates
May 16, 2016
Financial Management Series V
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Agenda
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Session Guidelines Announcements Maintenance 834 (M834) Updates Manual Workbook Submissions May and June Payment Cycles May PBP Transition May Payment Adjustment Examples Payment Dispute Updates Resources Closing Remarks
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Session Guidelines
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This is a 90-minute content session. Documented Q&As will be posted in the coming weeks. For questions regarding logistics and registration, contact the Registrar at: (800) 257-9520.
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FM Series V
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FM Series V will provide information related the 2016 transition to Policy-based Payments (PBP) and the Dispute Reporting Process, in addition to providing technical guidance related to the PBP payment process. As part of this series, Centers for Medicare & Medicaid Services (CMS) will conduct content webinars each Monday from 2:00 p.m. to 3:30 p.m. ET.
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FM Series V Dates: May 2016
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Day of Session Date of Session Time Session Type
Monday May 2, 2016 2:00 p.m. – 3:30 p.m. ET Webinar
Monday May 9, 2016 2:00 p.m. – 3:30 p.m. ET Webinar
Monday May 16, 2016 2:00 p.m.– 3:30 p.m. ET Webinar
Monday May 23, 2016 2:00 p.m. – 3:30 p.m. ET Webinar
Monday May 30, 2016 CANCELLED HOLIDAY
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Points of Contact
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CMS directs Issuers to contact the Federal Enrollment and Payment System (FEPS) Helpdesk with technical questions or issues. Issuers can contact the FEPS Helpdesk at the [email protected] email address.
CMS directs Issuers to contact the Marketplace Payments Team with questions related to the Manual Payment Process. Issuers can contact Marketplace Payments at the [email protected] email address.
CMS directs Issuers to contact the Financial Management Coordination Center (FMCC) with questions regarding the PBP process. Issuers can contact the FMCC at the [email protected] email address.
CMS directs Issuers to contact the Enrollment Reconciliation and Resolution (ER&R) contractor with questions regarding the discrepancy reporting process, as well with dispute form submissions. Issuers can contact the ER&R contractor at the [email protected] email address.
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PPR and HIX 820 File Issues
Please follow the escalation path below for issues with File Transfer Protocol (FTP) or locating the monthly Preliminary Payment Report (PPR) and HIX 820 payment files:
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PPR Contact the FMCC
Email: [email protected]
HIX 820 Contact the CMS Help Desk and request a Remedy Ticket for the issue. The Help Desk will assign the ticket to the appropriate support team who will reach out to Issuers to resolve.
Email: [email protected]
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Contacting FMCC
When contacting the FMCC, Issuers should include their five(5)-digit Health Insurance Oversight System (HIOS) ID and their seven-character Payee ID, along with their request.
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Additional Information
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Additional information related to the PBP transition is available in the Registration for Technical Assistance Portal (REGTAP) Library at the following links:
FM 2015 – 2016 Issuer Transition Guide, Version 4.4 https://www.regtap.info/uploads/library/FT_HIX820_Issuer_Transition_Guide_V4_4_5CR_032416.docx
PBP Temporary Adjustment Reconciliation Methodology https://www.regtap.info/uploads/library/FT_MPP_PBP_TempAdjustRecon_121815_v1_5CR_122115.pdf
May 2, 2016 Payment Bulletin https://www.regtap.info/uploads/library/FT_PaymentBulletin_v1_5C
PBP May Payment Back-out Example Workbook https://www.regtap.info/uploads/library/FT_PBP_May_Reversals_050216_5CR_050216.xlsx
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Dispute Resolution Form
The latest version of the Dispute Resolution Form is available on REGTAP at the following link: https://www.regtap.info/uploads/library/FT_PPR820__Dispute_Form_5CR_030416.xlsx
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2015 Restatements for SADPs
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For Stand-alone Dental Plans (SADPs) that did not submit data in 2015, or only sporadically submitted data:
CMS will require complete 2015 enrollment and payment data to be submitted during the June 2016 payment cycle in order to assess 2015 Federally-facilitated Marketplace (FFM) User Fees.
Further details outlining this process and outreach to the specific SADP issuers affected will be coming soon. 12
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Enrollment & Payment Data Workbook Update
In preparation for calculating Cost-sharing Reduction (CSR) reconciliation amounts in July 2016, CMS will no longer make adjustments to advance payments for CSR for 2014 or 2015 during May 2016.
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Enrollment & Payment Data Workbook 2015 Restatements
July 2016 will be the FINAL month in which Issuers can restate enrollment and payment data for the 2015 Benefit Year.
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M834 Launch
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The Basics: CMS is planning on launching the new “Maintenance 834” functionality between summer and OE2017.
M834s will allow for most changes to a policy to be reported by enrollees to maintain the same Exchange-assigned Policy ID. Note that certain changes will still trigger a termination and creation of a new policy (e.g. new coverage year, new application ID, change in Subscriber, etc.).
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Issuer M834 Readiness
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M834 readiness is critical to PBP payment accuracy. To update enrollment information and process payment with the Federally-facilitated Marketplace (FFM) after M834 is launched, issuers will need to be able to:
Receive/process and create/send initial and effectuation M834 transactions. Receive/process and create/send updated recon files.
System readiness for M834 will allow Issuers to keep enrollment data aligned with the FFM, supporting correct payment and correct 1095-As for consumers.
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Steps to M834 Readiness
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Timing: Since March 22nd, education has been rolled out to Issuers via the bi-weekly Tuesday 3:00 p.m. ET “CMS-Issuer Technical Work Group”.
Issuers are being prepped via webinar & live Q&A to be ready to test by summer. Summer sessions will roll-out Issuer testing of M834s. Pending system readiness and Issuer testing, goal is to launch in Production before all-Issuer end-to-end Open Enrollment testing begins in September.
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Steps to M834 Readiness (Continued)
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Issuers Need to: Download and implement new reconciliation specs:
CMS has updated the specifications to the RCNI, RCNO, and Pre-audit Files. Access update specs at: https://zone.cms.gov/document/2016-enrollment-data-reconciliationPlan to test with the FFM in July. Use new specifications for August 18, 2016 RCNI submission. Receive new formatted RCNO and Pre-audit Files on August 26, 2016.
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Steps to M834 Readiness (Continued)
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Issuers Need to: Review the M834 documentation posted at CMS zONE:
Version 1 of the Implementation 834 Guide: https://zone.cms.gov/document/federally-facilitated-marketplace-maintenance-834-operations-manual
Pre-Draft Version 2.0 of 834 Companion Guide at: https://zone.cms.gov/document/asc-x12-005010-834-companion-guide
Be ready to connect to and test in the new “IMPL2” testing environment in June. Issuers with questions on how to ensure their systems are ready should be attending the Tuesday workgroup and engaging in Q&A.
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New Workbook Submission Process
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CMS will be moving from using an Access Database to aggregate Issuer workbooks to an automated Oracle Database solution. To that end, Issuers will now be required to submit Manual Workbooks via Electronic File Transfer (EFT) to CMS beginning with the August payment cycle, required by the September cycle.
Current Process Currently, All Issuers email their Manual Workbooks to the following CMS email address: [email protected]
New Process : Beginning with the July 2016 data submission for the August Payment Cycle
SBMs will be required to submit workbooks via EFT.
FFMs will have the option to submit workbooks via EFT, but are not required to do so and may continue to send workbooks to the CMS email address.
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New Workbook Submission Process (Continued)
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New Process: July for the August Payment Cycle SBMs must be onboarded and must have successfully tested submitting via EFT.
FFMs that wish to submit via EFT must be on boarded and have successfully tested prior to production submissions.
New Process: EFT Usage Details Issuers must use new EFT Function Codes (defined on following slide) to transfer files via EFT to CMS.
Instructions on how to transmit workbooks via EFT will be provided in separate MFT documentation
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New Workbook Submission Process - New Function Codes
File Direction
Function Code File Name
Issuers to CMS
WBKI1A File Name: <TradingPartnerID>.OPR.WBKI1A.Dnnnnnn.Txxxxxxxxx.P.IN Example: <TPID>.OPR.WBKI1A.D160415.T142524123.P.IN Please note: This is a zip file and should be named with a .IN and not a .IN.ZIP file extension
CMS to Issuers
WBKO1A (Acknowledgement
of File Receipt)
File Name: <TradingPartnerID>.WBKO1A.Dnnnnnn.Txxxxxxxxx.P.OUT Example: <TPID>.WBKO1A.D160415.T142512123.P.OUT Please note-in order to save and open this file: This is a zip file and should be renamed from a file with a .OUT extension to a .ZIP extension in order to open it Renaming & Saving Example: <TPID>.WBKO1A.D160415.T142512123.P.OUT.ZIP
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MFT Thin Client Help Guide
Go to: https://eft.feps.cms.gov/cfcc/login/login.jsp Enter Username and Password Select Sign On For example User ID: FEP0458 and password
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Steps for uploading files: o Select the ‘Browse’
button beside ‘Upload’.
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MFT Thin Client Help Guide (Continued)
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Select ‘Run’ if security prompt is displayed.
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MFT Thin Client Help Guide (Continued)
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‘Choose file for’ window should appear displaying your folder structure.
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MFT Thin Client Help Guide (Continued)
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Navigate to file, highlight and click Open.
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MFT Thin Client Help Guide (Continued)
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Select ‘Allow’ if security prompt is displayed.
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MFT Thin Client Help Guide (Continued)
Notice the file path is now displayed in the upload ‘Local File Name’ field. Select ‘Upload’.
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MFT Thin Client Help Guide (Continued)
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Status message should display transfer complete.
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MFT Thin Client Help Guide (Continued)
This completes the file upload process. The following slides cover steps for downloading files.
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MFT Thin Client Help Guide (Continued)
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Select the ‘Browse’ button beside ‘Download’.
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MFT Thin Client Help Guide (Continued)
In left column, select download location by checking the corresponding box (Click key icon to expand/collapse folders) In right column, select the files to download by checking the corresponding box Select ‘OK’
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MFT Thin Client Help Guide (Continued)
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Select ‘Allow’ if security prompt is displayed.
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MFT Thin Client Help Guide (Continued)
The number of files selected should now appear in the download ‘Local File Name’ field. Click ‘Download’ button.
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MFT Thin Client Help Guide (Continued)
Status should display “Transfer Complete”. This completed the download process.
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New May Transition Guidance
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On May 2, 2016, CMS published new Policy-Based Payments Guidance revising the bulletins published on December 4, 2015 and March 22, 2016 in the REGTAP Library at the following link:
https://www.regtap.info/uploads/library/FT_PaymentBulletin_v1_5CR_051016.pdf
As noted previously, CMS is ending adjustments to Manual Workbooks in May. CMS will smooth the reversal of past adjustments over two (2) months for Issuers with positive payments whose submitted Workbooks exceed PBP. Guidance is available on the Center for Consumer Information and Insurance and Insurance Oversight (CCIIO) webpage at:
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Policy-Based-PaymentBulletin_050216.pdf
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After May Adjustments
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After the May adjustment: CMS will pay Issuers the calculated PBP, except in cases of extreme variation (>25%) from the manual payment amount. CMS will apply a manual payment adjustment to Issuers’ calculated PBP so that the Issuer does not receive less than 75% of the Manual Payment Process amount (capped at upper bound). This cap on variation will extend through the July payment cycle. To allow this calculation, Issuers should continue to submit Manual Workbooks for 2015 and 2016 until notified otherwise by CMS.
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Payment Dispute Updates
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Disposition / Dispute Detail Code Updates Issuer Disputes – Two Approaches Form Instruction Clarifications Semi-monthly Issuer Report
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Disposition / Detail Code Updates
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Payment Dispute Disposition and Detail Code List (v2) Publication coming soon New Disposition Codes New Dispute Detail Codes (formerly known as Error Codes)
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Disposition Code Updates
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New Disposition Codes I3 – In Process I4 – In Process C5 – Already Corrected by Adjustments
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Dispute Detail Code Updates
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New Dispute Detail Codes - Rejected/Returned Dispute
Information Code
Dispute Information Code Explanation Disposition Code
PD804 This Issuer’s disputes cannot be resolved because the issuer did not successfully submit an RCNI file, please contact the FMCC help desk at [email protected] for technical assistance.
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Dispute Detail Code Updates (Continued)
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New Dispute Detail Codes – Completed/Closed Dispute
Information Code
Dispute Information Code Explanation Disposition
Code
PD511 The Payment Dispute has been resolved by one or more original or adjusted payments in recent PPR /HIX 820 record(s). The Issuer may refer to recent PPR / HIX 820 records for the policy and coverage period for confirmation.
C5
PD521 The dispute does not contain any Issuer values and the current RCNO file reflects that the Premium Paid Indicator shows as Cancelled. The update should be reflected in the issuer's payment within 1-2 payment cycles. The Issuer should resubmit the Payment Dispute if the issue is not resolved after 2 payment cycles.
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PD1599 The current RCNO file reflects that an update to the Coverage Date(s) and/or Amount(s) in the FFM is pending and should resolve this dispute. The update should be reflected in the issuer's payment within 1-2 payment cycles. The Issuer should resubmit the Payment Dispute if the issue is not resolved after 2 payment cycles.
C3
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Dispute Detail Code Updates (Continued)
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New Dispute Detail Codes – In Process
Dispute Information
Code Dispute Information Code Explanation Disposition
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PD517 The disputed value contains a Field level flag value of "I" (Non-match, Issuer to update to FFM value) on the most recent RCNO file. The dispute is being investigated further by the ERR Contractor. The Issuer should refer to the Bi-Monthly Payment Dispute report to check for any changes to the status of this dispute.
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PD518 The disputed value contains a Field level flag value of "D" (Did not compare, No action required) on the most recent RCNO file. The dispute is being investigated further by the ERR Contractor. The Issuer should refer to the Bi-Monthly Payment Dispute report to check for any changes to the status of this dispute.
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PD519 The dispute contains a Record level flag value indicating that it is an orphan record on the most recent RCNO file. The dispute is being investigated further by the ERR Contractor. The Issuer should refer to the Bi-Monthly Payment Dispute report to check for any changes to the status of this dispute.
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Dispute Detail Code Updates (Continued)
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New Dispute Detail Codes – In Process Dispute
Information Code
Dispute Information Code Explanation Disposition Code
PD520 The dispute has FFM updates pending but contains a Record level flag value indicating that it is part of an uneven match on the most recent RCNO file. The dispute is being investigated further by the ERR Contractor. The Issuer should refer to the Bi-Monthly Payment Dispute report to check for any changes to the status of this dispute.
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PD600 The current RCNO file reflects that an update to the Coverage Date(s) and/or Amount(s) is pending and may resolve this dispute. The dispute is being investigated further by the ERR Contractor. The Issuer should refer to the Bi-Monthly Payment Dispute report to check for any changes to the status of this dispute.
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Issuer Disputes – Two Approaches
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Issuer disputes potentially affecting payment may be based upon:
Enrollment file format (Enrollment dispute form based upon RCNO data). Payment file format (Payment dispute form based upon PPR or HIX 820 data).
Either form can be used to report issues affecting payment. Payment disputes usually reflect enrollment data issues.
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Issuer Disputes – Two Approaches (Continued)
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Enrollment file format (Enrollment dispute form based upon RCNO data).
Offers the earliest opportunity to identify and initiate a dispute based upon enrollment data in the Pre-Audit File (dates and amounts) thereby ensuring correct payments based upon accurate data. Expedites the processing of Reinstatements and Rejected Enrollments because these do not require a match to the RCNI for processing. Can be used for other enrollment scenarios not supported by the payment file format such as Qualified Health Plan (QHP) ID discrepancies.
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Issuer Disputes – Two Approaches (Continued)
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Payment file format (Payment dispute form based upon PPR or HIX 820 data).
Based on PPR or HIX 820 to allow Issuers to automatically generate disputes based on their own payment systems. Can be used to dispute the User Fee (UF) amount that is not reported in the RCNO file; the UF is unique to the PPR. 52
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Payment Form Dispute Reminders
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For any field being disputed, the Issuer should populate: ISSUER values: consistent with the Issuer’s most recent RCNI submission.
FFM values: from the PPR or HIX 820.
Dates (Coverage Period Start/End)
Should always be populated, if a financial field is in dispute.
Disputed financial amounts always require FFM and Issuer dates.
Financial fields not in dispute should be left blank or be populated with 0/0.00
Non-disputed Issuer and FFM values should always match (both blank or both 0/0.00).
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Payment Form Dispute Reminders: Incorrect Payment
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The policy-month is on both Issuer records and the PPR/HIX 820, but at least one date or financial value is in dispute.
Two (2) options for non-disputed fields: Complete BOTH FFM and Issuer values for non-disputed fields with matching dates and financial values. Submit both FFM and Issuer values as BLANK or 0/0.00 for non-disputed fields.
FFM and Issuer Coverage Period Start/End dates are always required when financial values are disputed.
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Payment Form Dispute Reminders: Unexpected Payment
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Payment for a policy/month that the Issuer did not expect. Fill in ALL non-zero FFM values as shown on the PPR or HIX 820. Two (2) options for Issuer fields:
Report all Issuer values as zero (0)/0.00. Report all Issuer values as BLANK.
Issuer dates are not required since this policy-month does not exist in the Issuer’s system .
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Payment Form Dispute Reminders: Missing Payment
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Issuer expected a payment for a policy-month not listed. Fill in ALL non-zero Issuer values, consistent with the Issuer’s most recent RCNI submission. Two (2) options for FFM fields:
Report all FFM values as zero (0)/0.00 Report all FFM values as BLANK
FFM dates are not required since this policy-month is not on the PPR/820.
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Upcoming Payment Form Instruction Revision
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New payment dispute form iteration coming soon with updated instructions to reflect these reminders. No structural changes to the dispute form Issuers will be able to continue use the old form version
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Semi-monthly Issuer Report
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The Semi-monthly Issuer Report is distributed to Issuers twice a month – on the 1st and 15th, via EFT. Only sent to Issuers who have disputes that have had a change in disposition status since the preceding Semi-monthly Issuer Report. Includes four (4) tabs:
Enrollment Summary Enrollment Disputes Payment Summary Payment Disputes
Issuers should refer to the Semi-monthly Issuer Report to see if there has been a change in disposition status since the initial response file was received from the ERR Contractor.
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Semi-monthly Issuer Report (Continued)
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New function code ERRD Effective on the report dated May 15th. Used exclusively for transmitting the Semi-monthly Issuer Report.
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Semi-monthly Issuer Report (Continued)
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May 15th report: Updates on disputes that previously had a different Disposition Code as reported in the dispute response file.
Use Issuer Assigned Dispute Control Number (F2) on the dispute submission or CMS Dispute Control Number (F24) from the dispute response file to reconcile with dispute submissions.
Only supplies updates to disputes that have had a change in Disposition Code since the previous Semi-monthly Issuer Report (May 1, 2016 report, sent on May 2, 2016).
Many Issuers will see a large number of C5 dispositions (“Already Corrected by Adjustments”).
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Questions?
To submit questions by phone: •
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Dial ‘14’ on your phone’s keypad Dial ‘13’ to withdraw your question
To submit questions by webinar: Type your question in the text box under the ‘Q&A’ tab
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Acronyms Acronym Definition DSH Data Services Hub
EDI Electronic Data Interchange
EPS Enrollment and Payment System
FFM Federally-facilitated Marketplace
FMCC Financial Management Coordination Center
HIOS Health Insurance Oversight System
HIX Health Insurance Exchange
PBP Policy-based Payments
PPR Preliminary Payment Report
PSV Pipe-separated value
SBM State-based Marketplace
SHOP Small Business Health Options Program
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Resources
Resource Resource Link Centers for Medicare & Medicaid Services (CMS) http://www.cms.gov/
U.S. Department of Health & Human Services (HHS)
http://www.hhs.gov/
The Center for Consumer Information & Insurance Oversight (CCIIO) web page
http://www.cms.gov/cciio
Consumer website on Health Reform http://www.healthcare.gov/
ASC X12 Store http://store.x12.org/store/health-insurance-exchanges
Registration for Technical Assistance Portal (REGTAP) - presentations, FAQs
https://www.REGTAP.info
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Document Location
Additional Materials for FM Series IV are available in the REGTAP Library at https://www.REGTAP.info
Under Program Area, select “Payments – Remittance Message (X12 HIX 820)”
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Inquiry Tracking and Management System (ITMS)
Stakeholders can submit inquiries to ITMS at https://www.REGTAP.info
Select “Submit an Inquiry” from My Dashboard.
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FAQ Database on REGTAP
FAQ Database is available at https://www.REGTAP.info/
The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary Categories, and Publish Date.
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