Madena March 2017 Monthly Newsletter

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Madena News Corner

As we are heading into April, hopefully the dust is settling on your post-AEP activities. The largest amount of retroactivity in your plan systems and CMS reports will be in January – March, and we see the discrepancies across the industry normalizing heading into April.  We love the small window for Operations before AEP ramp-up begins once again in the summer because it provides the opportunity to step back and double check that the I’s are dotted and the T’s are crossed. Here are some new focus areas from CMS that we think Medicare organizations should be taking the time to look at end to end.


Is your Provider Online Directory Accurate?

CMS completed a review of 54 MAO Online Provider Directory that identified 45% were inaccurate resulting in 31 Notices of Non-compliance. The most common issues identified were:

  • Provider location listed was not valid
  • Provider was no longer contracted
  • Phone number, address or suite number incorrect
  • Provider was not accepting new patients

The second review is underway for another 64 MAO. Have you taken the necessary steps to ensure your Online Provider Directory is accurate?

  • Conduct an internal audit to determine any gaps
  • Communicate to providers the importance of reporting changes at the provider level not only at the group level.
  • Establish routine internal testing of provider data and outreach to providers
  • Create proactive approach for identifying if a provider data is incorrect (i.e. claims)
  • Consider including as requirement in provider contract as well as a central repository that can be used to make updates


Member credit card and bank acct information safe?

A security area that can be overlooked is member credit card and bank account information. The information can be in various forms: applications, inbound correspondence, authorization forms or verbally. Review your processes to confirm that there are reasonable and appropriate safeguards for protecting credit card information received from its members per the Payment Card Industry Data Security Standard (PCI DSS) and the HIPAA rules.

One call resolution beyond metrics…are you tracking and trending members who call back?

CMS has routinely discussed their expectation to look at your data to continually identify opportunities for improvement. We are huge fans of data analytics and the value of quantitative and qualitative data to develop a work plan to drive cross-functional improvements. Your plan should include:

  • Root cause analysis of calls received, Grievance and CTM
  • Collaboration with other departments to provide better communication to members (EOB, EOC/ANOC, website, member portal functionality)
  • Proactive processes in place to identify impact


Do you need assistance assessing your operations for gaps and improvement opportunities? Are you struggling to complete your 2017 enrollment and premium billing reconciliation? Our Madena Synchronicity™ Reconciliation Suite can be used to perform a one-time analytic output to help identify your discrepancies and identify your financial impact. Learn more information about how we can help
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CMS News Corner

Missing October and November 2016 Payments

CMS notified plans in the March 2017 payment letter that a data clean up identified and corrected missing 10/16 and 11/16 payments. Look for Adjustment Reason Code 94 with a clean up ID of RT6993395. If you are using your MMR for full plan monthly reconciliation, these may have created discrepancies that the staff ignored because MARx was showing the accurate enrollment span. Use this clean up as a training to your staff on the identification of ‘payment only’ discrepancies that should be reported to your plan leadership & accounting teams as well as the MAPD help desk. CMS addressing data issues are largely driven by plans identifying and reporting these issues.

Complaint Tracking Module (CTM) Update – LIS Determination

CMS has updated the Complaint Tracking Module (CTM) with a new function to allow MAOs to submit request for assistance with member’s LIS status when member cannot provide Best Available evidence (BAE). The cases should be entered within 1 day of being notified of LIS eligibility using lead category “Premiums and Costs-Beneficiary needs assistance with acquiring Medicaid eligibility information (EX)” and sub-category “CMS review/action”.  These cases will not be included in the CTM metrics.

CMS will notify MAOs of results via CTM .  MAO is responsible for updating systems to reflect correct LIS status and send attachment A or B from the 2/17/2017 HPMS memo Best Available Evidence Process Update. If MARx is not correct the CTM can be used as documentation when submitted to RPC. If member can provide BAE documentation, the existing BAE process from PDBM Chapter 13 Premium and Cost-Sharing Subsidies for Low-Income Individuals section 70.5 should be used. Make sure you have a copy of the new User Guide distributed via HPMS on 3/14/16.

New and Improved eRpt – Effective March 2017

Make sure your organization understands the eRpt system and process changes.

  • Email notification for all eRpt functions (rejected submissions, FDRs and EDV) will now be sent to all users that are approved for plan contracts. EIDM can be updated to unsubscribe, but this will stop all EIDM email notifications.
  • Proxy designation must be approved for all contracts in the submission.
  • CAT 3 now require selection of Regional Office, Contract and Account Manager. If multiple contracts in submission only one needs to be selected. Notification will be sent directly to Account Manager.
  • Plan Submitter must be approved for all contracts on the submission spreadsheet.
  • Delete document function now available when submission is in Draft status.

Where in the world is the Annual Full Replacement COB File notice?

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Do you have an Annual COB File plan?

For the past handful of years, CMS has published a Health Plan Management System (HPMS) notice reminding plans of the release of the Annual Full Replacement COB file.  Usually, the files are released between 3/20 – 4/14.  CMS is a bit behind but plans should expect this notice be distributed via HPMS soon.

In our experience, plans should still expect the COB re-sync files any day, and these files can only be identified based on larger files with higher volumes over a period of 3-5 days.  Because this is an annual process, we do not anticipate there will be a significant change in the timing of these files – just possibly the notice from CMS.

Reminders from our experts: Don’t load the files without having a plan in place!

  • The intended purpose of the file is to review your COB information in comparison to the once-a-year cumulative COB file. Don’t override updated information that has been submitted and not processed by ECRS.
  • Evaluate all PRM records and understand any impact to your members of applying un-validated information to pharmacy claims payment.
  • Cross-functionally evaluate using this file for the annual mailing. What is the impact on your call center or staff processing any returned COB information? Did you recently send a notice to the member within the last 6 months?


Madena’s Synchronicity™ COB module can assist plans in managing the annual full file as well as the daily files.  Our software is workflow enabled and highly configurable to your business rules combined with our industry leading expertise.  Our COB module will enable your organization to identify duplicates, create workflows based on record type or insurer and creates exports in your required format for ECRS submissions, print-mailing, data feed into your PBM, reporting to your Recovery contractor or any other business need.  Learn more by contacting Jennifer Young at

Madena February 2017 Monthly Newsletter

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Madena News Corner

Madena co-sponsored the Healthcare Education Associate’s (HEA) MA Accounting & Reconciliation 101 Boot Camp in Nashville, TN on January 30-31st.  The conference was a great success with many health care organizations getting into the weeds and sharing their secret sauce.  Special thanks to all the attendees who actively participated in discussions and shared the challenges facing their organization.  If you missed this conference, be sure to mark your calendar for upcoming events from HEA.

Madena is proud to announce the 2.0 version of our Reconciliation software, Madena Synchronicity™ MSP and COB modules that provides an integration of the CMS files into a web-based user interface with our WorkSync Manager™ to assign and manage your inventory with an on-demand reporting module. Also included are exports for member correspondence mailing, Part C & D claim systems data feeds and submission to CMS’ contractor. The business logic configuration and data extracts are highly configurable to integrate into your existing technology infrastructure. Our software ensures you are compliant and have the highest level of payment integrity and revenue optimization.

With the additions of Civil Monetary Penalties to the CMS Financial Audits in 2017, how confident are you in your current MSP and COB process?

The Madena Synchronicity™ difference:

  • Can be purchased as individual modules, MSP only or COB only, or as an integrated MSP and COB module
  • Low implementation costs, short implementation timeframes and affordable monthly fees
  • One, Two or Three Year contract terms
  • Built by an organization with in-depth Medicare Advantage health plan experience managing MSP/COB inventory and working with CMS and the Benefit Coordination & Recovery Center (BCRC)
Contact Us To Schedule a Demo

CMS News Corner

February 2017 Software Release

Are you Ready? Make sure your reporting and processes have been updated!

  • New Election Type J – Seamless Conversion Election Mechanism (SCEM)
  • Improved MSP Start/End date reporting – TRC 245/280/368
  • Enhanced Medicaid reporting for Dual status – Marx UI Medicaid Payment Screen, and Monthly MA Medicaid Status Data file and MMR Medicaid Indicator change
  • Expanded use for DRC 65 – Can now be used by non-EGWP plans


CTM Module Changes

CMS is unveiling a new and improved HPMS CTM Module scheduled in March 2017.  CMS just announced 2/17/17 that Best Available Evidence (BAE) real-time beneficiary assistance requests will be submitted through the CTM module so be sure to include your Operational staff managing BAE on the training session. We are excited about the new BAE submission process through CTM that will replace the BAE assistance process in the PDP LIS Chapter 13.  Not all operations staff works directly in the CTM module so this may be a change for your organization.  We recommend that you work with your Compliance team to modify your current process to the new CTM BAE submission process.  And don’t forget to update your BAE P&P!

New Integrated Denial Notice (IDN)

On 2/9/17 CMS announced a revised IDN must be in use by 4/10/2017. While the regulations have not changed, CMS’ new model provides more instructions to the member and health plan in completing the form. CMS expects plans to use the new IDN as soon as possible but no later than April 10th.

Don’t forget to download both the new form and the instructions from the CMS website. When implementing letter template changes, remember your FDRs!  Communicate and plan for the changes with your FDRs to avoid non-compliance.

New PCUG Issued

A New PCUG was issued on 2/28/2017 based on the February Software release.  You need to refer to both the February Software release and the PCUG to confirm any changes that you may have put into place to support the Software release.

Changes: DTRR, MMR and the new Medicare Advantage Medicaid Status Data File

PS – We are excited about the new Medicaid status file to get better status information in the hands of health plans. If you do not have a Medicaid reconciliation process in place, now is the time to consider it with the implementation of this new file.  Remember our best practice: look at the file, play around with the data and test scenarios/validity of the data – then establish a reconciliation process!

New eRPT version 4

The new eRPT v4 is expected to be released in mid-March.  There are new daily emails to plan users/proxies and changes to the package creation for CAT2 & CAT3.  The 3/1/2017 CMS User Group call provided training and User Guide.  It is important to make sure you follow the new set up steps and download the new submission spreadsheet from the Reed & Associates website to use in the eRPT version 4.  Make sure you are providing training that includes the new submission spreadsheet and eRPT user guide to all staff that manages the RPC process.  The last version of eRPT that was released caused some challenges for clients and they were locked out of the system for a month or more.  Be prepared for hiccups that may delay your ability to submit packets.

Need assistance integrating regulatory changes in your processes or systems?
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