“Soft” Edits Debut Today in Section 111 Reporting

Today marks the first significant update in Section 111 reporting logic in several years.  In November 2020 the Centers for Medicare and Medicaid Services (CMS) announced a new classification of “soft” edits that will take effect today (April 5, 2021).  The information below outlines what “soft” edits are and how they will change the way Section 111 reporting is done.

What are “Soft” Edits?

“Soft” edits are data validations returned by CMS for claim data that is non-consequential and/or irrelevant to establishing a primary payment situation. For example, if an injured party’s representative / attorney’s phone number is left blank, CMS will now accept the record and return a data validation requesting that the RRE provide a valid phone number.  Examples of “soft” edits include: Plan Contact information; Claimant Middle Initial, Zip+4, Phone and Phone Extension; and Representative Firm Name, Zip+4, Phone and Phone Extension. 

What Happens When a “Soft” Edit is Identified?

In total, there are 41 possible “soft” edits.  If a “soft” edit is triggered on a claim, CMS will accept the claim with a 01 or 02 Disposition Code, and return the “soft” edit(s) in the Claim Response File.  The “soft” edit can then be corrected in a subsequent Claim Input File to CMS.  Until now, invalid data in one of these 41 fields would have led to the rejection of the entire claim record.  With “soft” edits data issues that are innocuous and/or tangentially related to the core components of the claim are simply noted but the claim will be accepted by CMS.  Note, the 41 fields triggering “soft” edits are part of the 127 fields defined as being “optional” per CMS.  The additional “optional” fields include elements such as: Claimant 1 through 4 data and their Representatives; Inured Party Middle Initial; Industry Date of Incident; and Alleged Cause ICD Code.

How Has ECS Implemented “Soft” Edits Into the MIR Service and iService Reporting Platforms?

ECS has spent the last several months evaluating CMS’ updated guidance and incorporating the updated guidance into our MIR Service and iService reporting platforms.  During that period we have had numerous discussions with our valued clients as well as key personnel inside of the agency or its contractors. 

In support of our loyal customers and our continued commitment to ensure accurate, complete, and timely Section 111 reporting we have implemented the following changes, effective immediately:  ECS will cease validating these “optional” fields in your claim submissions, and cease populating these “optional” fields when submitting claims to CMS.  Reporting optional data is not required under the CMS’ Section 111 reporting guidelines.

ECS customers will receive substantial benefit from this adjustment, including: Fewer validation warnings to correct prior to reporting; streamlined reporting of claims to CMS; and easier to evaluate validation reports.  With Civil Money Penalties somewhere out there on the horizon, establishing practices that facilitate accurate, complete, and timely reporting is paramount and we are confident that this solution achieves that objective.

Since the inception of Section 111 reporting in 2010 MIR Service and iService have successfully reported tens of millions of workers’ compensation, no fault, and liability claims involving Medicare beneficiaries to CMS.  We remain committed to working with our customers to nimbly adapt to ever-more-frequent adjustments by CMS with simplified processes, reports, and technical upgrades.  Our Section 111 Compliance Team includes over a dozen individuals dedicated solely to assisting our MIR Service and iService clients – all of whom have at least ten years’ experience in facilitating Section 111 reporting. 

ECS will continue to closely monitor any Section 111 reporting changes and outline the critical context of those reporting 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 about your program 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