Minor Change at CMS Should Result in Quicker Claim Acceptance

On Monday, September 27, 2021, the Centers for Medicare and Medicaid Services (CMS) announced a minor, yet impactful change to their Section 111 processes.  October 4, 2021, CMS will accept a claim when the MSP effective date is up to three months in the future.  In turn, the CMS system will create an MSP record with the future MSP Effective Date.

What this means to you: Medicare eligibility is confirmed through the monthly query process, and there are times where a positive query response is somewhat premature because Medicare entitlement records may have effective dates up to three months in the future.  Historically, when a claim like this is reported to CMS, CMS generally returns an Error Code of “SP31” to indicate the claim was submitted prior to the Medicare entitlement date.  This situation requires that the claim be resubmitted the following quarter.  Starting 10/4/2021 however, if the beneficiary’s Medicare Entitlement Date is within 3 months, then CMS will accept the claim upon first submission.

Why this is important: Receiving an Error Code of “SP31” results in CMS not accepting the claim in their system until it is resubmitted after the occurrence of the Medicare Entitlement Date – i.e. 90 days later.  A lot can happen on a claim in 90 days such as additional and costly treatment, or perhaps even a settlement.  The longer it takes for CMS to get that claim into their system, a broader time gap exists for Conditional Payments to continue stacking-up.  This change will allow claims to be accepted by CMS sooner, thereby tightening the overall timeframe relative to Section 111.

ECS will continue to closely monitor any Section 111 reporting changes and outline the critical context of those changes to you.  Contact us today to learn more about how these changes may impact your claims process, or to learn more about our tailored Section 111 reporting solutions. Our Mandatory Insurer Reporting Team can be reached at MIRService.Support@examworkscompliance.com or 678-222-5454 to schedule an evaluation today.

Scott Huber

Scott Huber

Scott Huber is the Senior Vice President of Technology at ExamWorks Compliance Solutions. Scott oversees all internal and external technology services for ECS, including the award-winning MIR Service Section 111 Reporting platform. A native Floridian, Scott is a graduate of the University of Florida and works out of ECS headquarters in Lawrenceville, Georgia. Scott can be reached at 678-256-5135 or scott.huber@ExamWorksCompliance.com