The Centers for Medicare and Medicaid Services (CMS) has resolved the issue with the Section 111 mandatory reporting Medicare Eligibility Query matching process in which submission of a partial social security number (Last 5 digits) may result in claimants incorrectly being identified as Medicare beneficiaries. The prior announcement may be found here.
The normal Medicare Eligibility Query matching process first looks for a match on SSN and then attempts to match on three of the remaining four fields (first initial of the first name, first six letters of the last name, gender and date of birth). This works well when the full 9-digit SSN is provided, however providing a partial SSN introduces the possibility of a "false positive" response from the Query; it is possible for two people to share the same partial SSN, first initial of the first name, first 6 letters of the last name and gender. That meets the "3 of 4" criteria and an incorrect match could be returned.
To resolve the issue and greatly reduce the potential for false positive responses, CMS has changed their matching process when a partial SSN is provided. Now, when a partial SSN is provided, CMS will attempt to match on all four of the remaining fields. If all four fields match, either the "DP" (Duplicate Possible) response will be provided if there is more than one potential match, or a positive Medicare Eligibility response will be provided. The CMS Technical Alert may be found here.
In order to mitigate the issue and cease returning false positive responses, CMS paused processing of Query Input Files for the last several days. This may result in a delay in receiving responses for files submitted in June.
ExamWorks Clinical Solutions has analyzed the Query Responses from CMS and determined that an extremely small subset of clients had been affected by the matching issue at CMS. These clients have been contacted and remediation steps are in place.
ExamWorks Clinical Solutions continues to recommend that the full SSN be obtained and used for the Medicare Query process as it greatly improves the accuracy of the Query and eliminates the possibility of false positive results.
ExamWorks Clinical Solutions will continue to keep you apprised of all relevant Medicare Secondary Payer compliance developments.
ExamWorks Clinical Solutions