Common Questions

ANSWER: The Claim List is detailed claims data that supports the Summary Cost Report amounts included in the reimbursement request. The detailed claims data must only include items or services from claims incurred within the approved time periods reported on the Early Retiree List Response file. The Claim List must include the claim items or services for which the Plan Sponsor is currently requesting reimbursement, as well as all the items or services for which the Plan Sponsor has requested reimbursement in previous reimbursement requests for that plan year. In other words, the detailed claims data must be cumulative and each Claim List replaces the previously submitted Claim List(s) for the plan year. Please see ERRP Training Presentation: Claim List for more detailed information on the Claim List.

Answer ID: H200-53
Date Posted: 04/17/2011

ANSWER: The ERRP Center will accept a Claim List one of two ways: uploaded to the ERRP Secure Website (SWS), or transmitted via a Sponsor's or specified vendor's mainframe connection to the ERRP Data Center Mainframe. The Plan Sponsor will specify which submission method it is using in the ERRP SWS.

Minimal setup is required for ERRP SWS submission; however, there is a 100MB upload limitation. The ERRP Center requires that all Claim Lists greater than or equal to 100MB be submitted via mainframe (a 100MB Claim List contains approximately 249,000 claim service lines).

If a Sponsor intends to transmit Claim Lists via a mainframe connection and does not already have an existing mainframe connection, it is necessary to contact the ERRP Center as soon as possible to begin the setup process.

Answer ID: H200-54
Date Posted: 04/17/2011

ANSWER: A Plan Sponsor should submit a Claim List when requesting reimbursement, or after receiving notice that a Claim List was rejected. Each Claim List submission to the ERRP Center must be a full replacement of the previously submitted Claim List.

Answer ID: H200-55
Date Posted: 04/17/2011

ANSWER: In addition to assigning the View/Send/Receive Claim File Data privilege to the Designee(s), the Plan Sponsor must also identify a Technical Contact and provide the following information about that person: First Name, Last Name, Telephone, Fax, and E-mail Address. The ERRP Data Center will contact the Technical Contact to set up and test the connection.

The time frame for Mainframe to Mainframe setup varies depending on the Plan Sponsor's vendor. If Mainframe to Mainframe submission is preferred, it is necessary to call the ERRP Center as soon as possible to begin the setup process.

Note: The ERRP Center requires that Claim Lists greater than or equal to 100MB be submitted via Mainframe method.

Answer ID: H200-56
Date Posted: 04/17/2011      Last Updated:06/03/2011

ANSWER: Click here for the detailed Claim List Secure Website layout. Claim Lists submitted via Secure Website submission method must be submitted in .CSV file format. Claim List Secure Website layouts must meet the following requirements:

1. One or more detail (professional, institutional, or prescription) records and one trailer record

2. Named with a .csv extension

3. Variable length comma delimited file/records

4. Variable field lengths separated by commas

Note: The ERRP Center requires that Claim Lists greater than or equal to 100MB be submitted via Mainframe method.

Answer ID: H200-57
Date Posted: 04/17/2011      Last Updated: 05/12/2011

ANSWER: Click here for the detailed Claim List mainframe layout. Claim List mainframe layouts must meet the following requirements:

1. One header record, one or more detail (professional, institutional, or prescription) records, and one trailer record

2. Fixed length file/records

3. Fixed field lengths

4. Unless otherwise stated, all fields are defined as alpha numeric (Cobol PIC X) and left justified

Note: The ERRP Center requires that Claim Lists greater than or equal to 100MB be submitted via Mainframe method.

Answer ID: H200-58
Date Posted: 04/17/2011      Last Updated: 05/12/2011

ANSWER: If an error message is received while uploading a Claim List, this indicates that the Claim List has been rejected and must be uploaded again. Click here to review the Claim List Errors. If a Claim List fails the validity checks, the following actions will occur approximately five (5) business days after Claim List submission:

• The ERRP Secure Website (SWS) Display Claim List page will display the status for submitted Claim Lists.

• The ERRP Center will send an email to the Authorized Representative (AR), Account Manager (AM), and/or Designee(s) assigned View/Send/Receive Claim Data privilege stating that the Claim List submission was unsuccessful.

A representative of the ERRP Center will contact the Plan Sponsor to explain why the Claim List failed validity checks and to discuss possible solutions.

Answer ID: H200-59
Date Posted: 04/17/2011

ANSWER: Claim List statuses are displayed on the Display Claim List page on the ERRP SWS. With the automated Claim List Review process, a Claim List can be in any of the following statuses as displayed on the ERRP SWS:

• Uploaded – Claim List uploaded via ERRP SWS successfully.

• Submitted – Claim List uploaded via ERRP SWS passed file level editing.

• Error Found – Claim List uploaded via ERRP SWS did not pass file level editing. Plan Sponsor will need to review errors and resubmit.

• Received – Claim List passed initial validity checks and will, next, be subject to the ERRP Center’s automated Claim List review process.

• Accepted (CLRF sent) – Claim List passed the automated Claim List review process and a Claim List Response File has been created/sent. ERRP Center sent an email advising the Plan Sponsor and its appropriate Designee(s) that the Claim List processed successfully. (Note that a CLRF will be sent via the same submission method the Claim List was sent to the ERRP Center. Once the Claim List is in an 'Accepted' status in the ERRP SWS, the Plan Sponsor may submit a Summary Cost Report and continue with the reimbursement process.)

• Invalid (CLRF sent) - Claim List did not pass the automated Claim List review because errors were found. ERRP Center will send an email advising the Plan Sponsor and its appropriate Designee(s) that the Claim List processed unsuccessfully. (Note that a CLRF will be sent via the same submission method the Claim List was sent to the ERRP Center. The CLRF will indicate the records in error and their respective reason codes. The Claim List must be corrected based on the information described in the CLRF and resubmitted. Reminder: Each Claim List submission is a full file replacement of the previously submitted file. Do not only resubmit the claim records in error.)

• Obsolete – Claim List is no longer valid since a new ERL was subsequently submitted. A new Claim List is required before requesting reimbursement.

• Not Processed - Claim List was not processed by the ERRP Center for one of the following reasons: 1) A subsequent Claim List was received prior to processing (i.e., the Claim List was replaced by a new Claim List), or 2) an Early Retiree List was in process and not effective when the Claim List was submitted.

Answer ID: H200-60
Date Posted: 04/17/2011      Last Updated: 10/01/2011

ANSWER: Beginning October 3, 2011, the ERRP Center implemented an automated Claim List review process which will produce a Claim List Response File (CLRF). The CLRF will indicate whether errors were found on the Claim List. If errors were found, the CLRF will identify the specific records with errors and the type of error(s) found.  For more information about the Claim List Response File, please refer to the Claim List Response File Reference Guide.

Answer ID: H1100-33
Date Posted: 10/01/2011

ANSWER: The ERRP Center communicates that a Claim List has passed the automated Claim List process (i.e. the Claim List status is 'Accepted') using several methods:

• The ERRP Center sends an email advising the Plan Sponsor that the Claim List was error-free and was set to an 'Accepted' status.

• The ERRP Secure Website Claim List status reflects a value of 'Accepted'.

• A Claim List Response File for an 'Accepted' Claim List will only have two records; one that starts with an 'H' for Header and one that starts with a 'T' for Trailer (i.e. no records that start with a 'D' for Detail).

• A value of 'AC' (Accepted) will be in the Header (H) record of the Claim List Response File.

If the Claim List is 'Accepted', then the Plan Sponsor may submit a Summary Cost Report and continue with the reimbursement process.

Answer ID: H1100-34
Date Posted: 10/01/2011

ANSWER: The ERRP Center communicates that a Claim List was unsuccessfully processed (i.e. the Claim List status is 'Invalid') using several methods:

• The ERRP Center sends an email advising the Plan Sponsor that the Claim List had errors and the status was set to 'Invalid'.

• The ERRP Secure Website Claim List status reflects a value of 'Invalid'.

• A Claim List Response File for an 'Invalid' Claim List will have three record types; one record starts that with an 'H' for Header, one or more records that starts with a 'D' for Detail, and one record that starts with a 'T' for Trailer. The 'D' records identify the Claim List records that contained errors and the type of error(s) found.

• A value of 'IN' (Invalid) will be in the Header (H) record of the Claim List Response File.

If the Claim List contained errors, the Summary Cost Reporting capability will remain unavailable in the ERRP Secure Website, for the subject application plan year, until an error-free Claim List is received and the Claim List status is set to 'Accepted'.

Answer ID: H1100-35
Date Posted: 10/01/2011

ANSWER: The Claim List Response File (CLRF) will be delivered to the Plan Sponsor via the same method the Claim List was submitted. If the Plan Sponsor selects 'Submission via ERRP SWS', then the CLRF will be available for download via the ERRP SWS. If the Plan Sponsor selects 'Submission via Plan Sponsor Mainframe to ERRP Data Center Mainframe' or 'Submission via Vendor Mainframe to ERRP Mainframe', the corresponding CLRF only be returned to the Plan Sponsor's (or Vendor’s) Mainframe (i.e. a CLRF will not appear in the ERRP SWS).

If a CLRF is not listed on the "Download Claim List Response Files" page, it may be for one of the following reasons:

• The Claim List Response File is not yet available.
  (If the Claim List is uploaded to the ERRP SWS, the corresponding CLRF will be made available for download on the ERRP SWS approximately five business days after Claim List submission. The ERRP Center will send an email when a CLRF is available for download.)
  

• The chosen Claim List Submission Method is not 'Submission via ERRP SWS'.
  (If the Claim List was submitted to the ERRP Center using Plan Sponsor Mainframe to ERRP Data Center Mainframe or Vendor Mainframe to ERRP Mainframe, the corresponding CLRF will not appear on the ERRP Secure Website.)

Answer ID: H1100-36
Date Posted: 10/01/2011

ANSWER: Claim List Response File (CLRF) Reason Codes are codes that correspond to a specific message about an error found in a Claim List record. Each record in a CLRF can display up to four reason codes at a time. If the CLRF includes a claim line detail with four reason codes, the Plan Sponsor is strongly encouraged to review all data elements in the Claim List that was submitted and try to identify other potential errors. For information about CLRF Reason Codes, please review the ERRP Claim List Response File Reason Codes.

Answer ID: H1100-37
Date Posted: 10/01/2011

ANSWER: Yes. A Claim List will be rejected when an optional field is populated with an invalid value, such as alphabetic characters in a numeric field, numeric characters in an alphabetic field, or the incorrect number of characters in a fixed-length field. To avoid these scenarios, leave optional fields blank unless you are sure you have populated the fields with valid values.

Answer ID: H1100-38
Date Posted: 10/01/2011

ANSWER: If a Claim List is 'Invalid', the Plan Sponsor needs to examine the errors reported in the Claim List Response File (CLRF), correct them, and then resubmit a revised Claim List. The tool you should use to interpret the Claim List Response File (CLRF) is the ERRP Claim List Response File Reason Codes document, which is found on www.errp.gov under the Reference Materials section. The ERRP CLRF Reason Codes document is an online reference tool for Claim List fields and their associated CLRF reason codes.

Reminder: Each Claim List submission is a full file replacement of the previously submitted file. Do not resubmit only the claim records in error.

Answer ID: H1100-39
Date Posted: 10/01/2011

ANSWER: No. A Claim List will go through all five levels (I – V) of automated processing sequentially. Once an error is received, generally, the Claim List will not continue through the next level of processing. Specifically, Claim List processing starts with Level I (File Format / File Submission Level Edits). If errors are found, no further processing occurs; a Claim List Response File (CLRF) is not generated. Instead the Plan Sponsor will receive a phone call from the ERRP Center to discuss the errors that were generated.

If a Claim List passes Level I editing, it continues processing through Level II (File Level Edits). If errors are found in Level II, no further processing occurs; a CLRF is generated. If a Claim List passes Level II it continues processing through Level III (Field Level Edits/Validate ERRP Eligibility Periods). If claim errors are found in Level III, that claim and all other claims for that particular individual early retiree stop processing at the end of Level III; the early retiree's claims do not proceed to Level IV. The only claims that proceed to Level IV processing are claims for individual early retirees that did NOT have an error in Level III. A CLRF is not generated until the end of Level IV (Person Level Edits and Duplicate Processing) processing and includes both Level III and Level IV edits as applicable. If a Claim List passes Level III and Level IV editing, it continues processing through Level V (Trailer Validation) as applicable. A Claim List passing Level V editing is accepted and the Plan Sponsor may continue through the reimbursement process.

Note: All claims in a Claim List will complete processing the respective level edits regardless of where in the file the error occurs. For example, if an error is encountered in Level II processing, all the claims will complete Level II processing and be addressed on the CLRF as applicable.

Answer ID: H1100-40
Date Posted: 10/01/2011

ANSWER: No. Claim Lists failing Level I processing do not get a Claim List Response File (CLRF). Instead the Plan Sponsor will receive a phone call from the ERRP Center to discuss the errors that were generated. Once a Claim List passes Level I editing, a CLRF will always be generated by the ERRP Center.

Answer ID: H1100-41
Date Posted: 10/01/2011

ANSWER: Yes. If errors are found in any of the Claim List records, the entire Claim List will be rejected (i.e. assigned the status of 'Invalid' in the ERRP SWS) and the Plan Sponsor will not be permitted to request reimbursement for that application plan year. If a Claim List has errors, the Plan Sponsor must resolve the data errors as soon as possible and resubmit their Claim List. The ERRP Center must receive an error-free Claim List (i.e. assigned the status of ‘Accepted’ in the ERRP SWS) before the Plan Sponsor can enter and submit Summary Cost Data and submit a reimbursement request.

Reminder: Each Claim List submission is a full file replacement of the previously submitted file. Do not resubmit only the claim records in error.

Answer ID: H1100-42
Date Posted: 10/01/2011

ANSWER: There are two emails a Plan Sponsor can receive from the ERRP Center related to a Claim List submission. Each email provides the Plan Sponsor with information about the status of the Claim List and/or Claim List Response File (CLRF). The two different emails are as follows:

ERRP Claim List Submission Unsuccessful: The Plan Sponsor will generally receive this email five business days after Claim List Submission. This email will inform the Account Manager; Authorized Representative; and Designee(s) with the View/Send/Receive Claim Data privilege, the Request Reimbursement privilege, or the Report Costs privilege that the Claim List was determined to be invalid. This means the Claim List status has been updated from a 'Received' status to an 'Invalid' status on the ERRP SWS. Since the Claim List had errors, the Summary Cost Reporting capability will remain unavailable in the ERRP SWS for the application plan year until an error-free Claim List is received.

ERRP Claim List Submission Successful: The Plan Sponsor will generally receive this email five business days after Claim List Submission. This email will inform the Account Manager, Authorized Representative, and Designee(s) with the View/Send/Receive Claim Data privilege or the Report Costs privilege that a Claim List was determined to be error-free. This means the Claim List status has been updated from a 'Received' status to an 'Accepted' status on the ERRP SWS. Once a Claim List is in an 'Accepted' status, a Plan Sponsor is eligible to submit a Summary Cost Report and can continue through the reimbursement process.

Answer ID: H1100-43
Date Posted: 10/01/2011

ANSWER: No. When applying adjustments to claims eligible for the ERRP program, a negative paid claim amount is not permitted. ERRP requires that the claim amount reported is the net of all adjustments; the net should never result in a negative balance. Such adjustments can be reflected quarterly when full file replacement Claim Lists are submitted with a Plan Sponsor's reimbursement request.

Answer ID: 1100-1
Date Posted: 07/18/2011

ANSWER: If Claim Line Item Numbers are not assigned, the Plan Sponsor must assign such numbers (e.g. default to 01, 02, etc.), as applicable, so that each claim and claim line is unique and traceable back to Claim List Response File edits. Without this level of unique traceability, the value of the Claim List Response File is diminished. For audit purposes, the methodology for the assignment of the Claim Line Item Numbers should be retained,and be able to be explained, by the Plan Sponsor.

Answer ID: 1100-2
Date Posted: 07/18/2011

ANSWER: Yes. The ERRP Center will accept the same Claim Number for different Member ID / Member Group ID combinations due to the remote possibility that different insurance carriers assign the same Claim Number to two different members. However, multiple claims with the same claim number may cause the Plan Sponsor confusion when reviewing Claim List Response Files returned from the ERRP Center, since the Claim Number and Line Number will be the unique identifiers of a record in the Claim List Response File. To ensure complete traceability back to Claim List Response File edits, the ERRP Center recommends a Claim List contain only unique Claim Numbers, even if this means reassigning Claim Numbers assigned by the claim processing system as necessary. Upon audit, a Plan Sponsor will be required to trace a reassigned Claim Number back to the original Claim Number assigned by a carrier.

Answer ID: 1100-3
Date Posted: 07/18/2011

ANSWER: When reporting adjusted claims, use the Plan Paid Date and Claim Line Number associated with the most recently adjudicated claim adjustment. With respect to the Plan Paid Date, for example, if a claim was paid on 1/13/2011 for $100.00 and was adjusted on 4/25/2011 resulting in a total paid amount of $75.00, the Plan Paid Date should reflect the 4/25/2011 adjustment date with the net amount of $75.00. Such adjustments can be reflected quarterly when full file replacement Claim Lists are submitted with a Plan Sponsor's reimbursement request.

Answer ID: 1100-4
Date Posted: 07/18/2011

ANSWER: A "derived claim" is one in which an item or service was paid other than on a fee-for-service basis, such as through a capitated arrangement or staff model. If the incurred cost of at least one item or service from the encounter is derived, and other items or services on the claim are paid on a fee-for-service basis, the Claim Derived Indicator value should be a 'Y' (i.e. the costs associated with the claim will be considered derived).

When submitting using the Mainframe Claim List layout, there is one header record per claim, which includes the Claim Derived Indicator field. In the scenario previously mentioned, if at least one item or service is derived, then the Claim Derived Indicator field should be 'Y'.

When submitting using the SWS Claim List Layout, there is no claim header record; each detailed line item contains the Claim Derived Indicator field. In the scenario previously mentioned, the Claim Derived Indicator field should accurately reflect whether the incurred cost of the specific item or service detailed in the claim line was derived or not.

Answer ID: 1100-5
Date Posted: 07/18/2011

ANSWER: No. With respect to reporting any rebate or price concession amounts related to prescription drug costs, the purpose of the Cost Adjustment Amount field is to report only those price concessions received after the point-of-sale, not those received at point-of-sale. Additional price concession guidance has been published by CMS. Refer to Allocating Post-Point of Sale Negotiated Price Concessions to Individual Early Retirees Under the Early Retiree Reinsurance Program for additional information.

Answer ID: 1100-6
Date Posted: 07/18/2011

ANSWER: No, the claim should not be included in the Claim List for the next reimbursement request. If a Plan Sponsor has a claim that was adjusted, and the net of that adjustment results in an amount paid of zero, that claim is no longer eligible for ERRP reimbursement because the sum of the Item Plan Paid Amount and the Cost Paid by Early Retiree fields is not greater than zero. Such adjustments can be reflected quarterly when full file replacement Claim Lists are submitted. In this case, the adjustment would be reflected by not including the claim in the full file replacement Claim List.

Answer ID: 1100-7
Date Posted: 07/18/2011

ANSWER: No. In this scenario, only the first three line items (and their associated costs) must be included in the Claim List and reflected in the either the Costs Paid by Plan and/or Cost Paid by Early Retiree fields in the Summary Cost Data. The amount of costs from the third line item that exceed the cost limit must also be reported in the Limit Reduction field in the Summary Cost Data. The fourth and fifth line items should neither be included in the Claim List nor reported in the Summary Cost Data.

Answer ID: H1100-8
Date Posted: 07/18/2011

ANSWER: If the Type of Bill is not available for your Institutional claims, for inpatient acute hospital bills, populate this field with a value of "999." When Type of Bill is not available for all other Institutional claims, populate this field with "000." When the Type of Bill field is populated with a "999" or any value starting with "11", the admission date is the incurred date. Otherwise, the From Date is the incurred date.

Answer ID: 1100-9
Date Posted: 07/18/2011

ANSWER: The Principal ICD Procedure Code is not a required field, per se. It is situational. If a procedure was performed, then the Claim List must include a valid procedure in the Principal ICD Procedure Code field in order for the costs to be reimbursable or credited toward the cost threshold. If a procedure was performed, and a Plan Sponsor is unable to report a valid procedure in the Principal ICD Procedure Code field, the Plan Sponsor must omit the costs for the procedure from the Claim List, and from Summary Cost Data.

Answer ID: 1100-10
Date Posted: 07/18/2011

ANSWER: The Principal Diagnosis Code field is required on all institutional and professional claims submitted to the ERRP Center on a Claim List. If unable to provide the Principal Diagnosis Code for such a claim, that claim is not eligible for reimbursement through the ERRP. Please omit such claims from the Claim List and from Summary Cost Data.

Answer ID: 1100-11
Date Posted: 07/18/2011

ANSWER: The Rendering Provider ID, Facility Provider ID, and/or Prescription Service Provider ID fields (referred to as Provider ID fields for this answer) are required on all claims submitted to the ERRP Center on a Claim List. When choosing to report using the "Plan Provider ID" or "Other" Provider ID option, a given Provider ID must be unique and consistently applied to a specific provider throughout the Claim List. In instances where the Rendering Provider ID is not available, Plan Sponsors may submit the billing Provider ID number instead. If unable to report unique and consistent Provider IDs in the Claim List, the Plan Sponsor should email the ERRP Center (help@errp.gov) for further direction. Absent a CMS-approved methodology for populating the Provider ID fields in a manner other than specified in the Claim Layouts, the Plan Sponsor must omit claims without a unique and consistent Provider ID from the Claim List.

Answer ID: 1100-12
Date Posted: 07/18/2011      Last Updated: 09/12/2011

ANSWER: The Provider ID Qualifier field is required because it informs the ERRP Center about the type of data contained in the various Provider ID fields (e.g. Rendering Provider ID, Facility Provider ID, and Prescription Service Provider ID). If the Plan Sponsor is unable to report either the National Provider Identifier (NPI), Social Security Number (SSN), Employer Identification Number (EIN), Plan Provider ID, National Association of Boards of Pharmacy (NABP) ID, or Drug Enforcement Administration (DEA) identifier, then the Plan Sponsor may report using an "Other" type of Provider ID in the applicable Provider ID Qualifier field. In instances where the Rendering Provider ID is not available, Plan Sponsors may submit the billing Provider ID number instead. Refer to the Claim List layouts on the Reference Materials page for specific code values for the field.

Answer ID: 1100-13
Date Posted: 07/18/2011      Last Updated: 09/12/2011

ANSWER: The Service Location Zip Code field is required on all claims submitted to the ERRP Center on a Claim List in order to ensure that the service or item was furnished in the United States, pursuant to the policy guidance published on September 28, 2010. Further, for derived health benefit costs reported by a Plan Sponsor pursuant to capitated or other arrangements, the Service Location Zip Code is important because it may be used to determine whether the derived cost amount that the Plan Sponsor submits for a health benefit item or service is reasonable in light of the specific market served. If unable to provide the Service Location Zip Code for a claim line, Plan Sponsors may submit the billing or rendering provider zip code. If neither of those are available, but the Plan Sponsor is certain the item or service was provided in the U.S., it should contact the ERRP Center to discuss alternative means of documenting the location of the provider or supplier for the claim(s) in question.

Answer ID: 1100-14
Date Posted: 07/18/2011      Last Updated: 09/12/2011

ANSWER: Yes. A Plan Sponsor that requested reimbursement prior to April 2011, and subsequently received reimbursement, for a given plan year, is required to submit a Claim List on or before March 30, 2012. The Claim List must be error-free and included in a reimbursement request submitted to the ERRP Center, in order to substantiate the amount that was reimbursed. If a Plan Sponsor fails to do so by the deadline, then the reimbursed amount will be determined to be unsubstantiated, and CMS will initiate processes to collect such amount back from the Plan Sponsor.

Answer ID: H1100-15
Date Posted: 07/18/2011      Last Updated: 09/23/2011

ANSWER: Yes, all Plan Sponsors that received reimbursement for such a reimbursement request must submit an error-free, full-replacement Claim List that passes CMS' automated edits and substantiates the previous reimbursement received, and submit an associated reimbursement request, by March 30, 2012. CMS will initiate procedures for recoupment of reimbursement paid to Plan Sponsors that do not meet this deadline. Any such funds returned to the program will be used to pay outstanding reimbursement requests in the order in which they were received.

Answer ID: H1100-44
Date Posted: 03/09/2012

ANSWER: Yes, all Plan Sponsors that received reimbursement for such a reimbursement request must submit an error-free, full-replacement Claim List that passes CMS' automated edits and substantiates the previous reimbursement received, and submit an associated reimbursement request, by March 30, 2012. CMS will initiate procedures for recoupment of reimbursement paid to Plan Sponsors that do not meet this deadline. Any such funds returned to the program will be used to pay outstanding reimbursement requests in the order in which they were received.

Answer ID: H1100-45
Date Posted: 03/09/2012

ANSWER: It depends. Mainframe files are subject to two levels of edits during submission to the ERRP Center: file-level editing and application-level editing. Mainframe files must first pass file-level editing before application-level editing occurs. Errors at the file level result in rejection of the entire Mainframe file. Errors at the application-level result in the rejection of only those Claim Lists found to be in error. If the Plan Sponsor submits a Mainframe file that includes Claim Lists for multiple applications, and any of the Claim Lists do not pass file-level editing, all Claim Lists for all applications included in that Mainframe file will be rejected before application-level editing occurs. If that Mainframe file passes file-level editing, it will then be subject to application-level editing. If an error occurs at the application-level, only Claim Lists found to be in error will be rejected.

Answer ID: H1100-16
Date Posted: 07/18/2011

ANSWER: Once the Early Retiree Paid Amount is applied to the new claim, on the next Claim List submitted to the ERRP Center, apply the Early Retiree Amount to the new claim and remove the amount from the adjusted claim.

Answer ID: 1100-17
Date Posted: 07/18/2011

ANSWER: No. Do not include dashes in any of the NDC fields. In addition, when an NDC is submitted it should be exactly eleven (11) digits. To account for this, CMS uses an 11-digit number, using an implied 5-4-2 format with a 0 inserted to pad whichever of the 3 segments does not match that format. This format was adopted by data standards selected pursuant to the HIPAA regulation.

Examples:

The following 3 NDC numbers could represent 3 different scenarios:

• 12345-6789-0

• 12345-6789-0 becomes 12345-6789-00 which becomes 12345678900 (i.e. adding a zero prior to the value in the 3rd segment).

• 1234-5678-90

• 1234-5678-90 becomes 01234-5678-90 which becomes 01234567890 (i.e. adding a zero prior to the value in the 1st segment).

• 12345-678-90

• 12345-678-90 becomes 12345-0678-90 which becomes 12345067890 (i.e. adding a zero prior to the value in the 2nd segment).

Answer ID: 1100-18
Date Posted: 07/18/2011

ANSWER: The "v" represents an implied decimal point. The numbers to the left of the "v" represent the numbers to the left of the decimal point. The numbers to the right of the "v" represent the numbers to the right of the decimal point.

For example, the Item Plan Paid Amount, defined as 7v2, is $543.21. The numeric value submitted should be 54321 within the SWS Claim List and 000054321 within the mainframe Claim List.

Answer ID: 1100-19
Date Posted: 07/18/2011

ANSWER: Yes, as long as such costs are otherwise eligible to be submitted for ERRP.

Answer ID: 1100-20
Date Posted: 07/18/2011

ANSWER: The following six fields should have the same data on both the Early Retiree List (ERL) and the Claims List:

Answer ID: H1100-21
Date Posted: 07/18/2011

ANSWER: Claims for the same Early Retiree do not have to be grouped together or placed in any particular order; however, line items from the same claim must be grouped together. Further, within the Claim List mainframe layout, the lines immediately following the claim header must be claim lines associated to the claim header. Finally, it is important to remember for Secure Website Claim List submissions to always include the file trailer record last in the file. Also, there should never be a reason to include more than one file trailer record in a Claim List.

Answer ID: 1100-22
Date Posted: 07/18/2011

ANSWER:

Institutional Claims

For an institutional claim, to report health benefit items or services for which payment by the Plan Sponsor (or plan) to a provider was bundled, the value 'XXXX' must be used in the Revenue Code (DI22) field and reported on a separate claim line detail record. Also, one or more claim line detail records, immediately following the claim line with the 'XXXX' entered in the Revenue Code (DI22) field, must include the details about the items and/or services that were paid by the plan in the bundled payment. Do so by making Item Plan Paid Amount (DI31) equal to $0 AND by populating one or more of the following fields with a valid value: Principal ICD Procedure Code (DI16), Revenue Code (DI22), and/or Procedure Code (D123). Without one or more of these fields populated with valid values on subsequent lines to identify the bundled services, the claim, and therefore the entire Claim List, will be rejected.

Multiple claim detail lines for a single claim may have the 'XXXX' Revenue Code (DI22); however, the claim line with 'XXXX' must always be followed by a claim detail line(s) that has one or more of the previously mentioned fields: Principal ICD Procedure Code (DI16), Revenue Code (DI22), and Procedure Code (DI23) and an Item Plan Paid Amount (DI31) equal to $0 before the next bundled ('XXXX' Revenue Code) line.

The Item Plan Paid Amount (DI31) for the claim detail line with the 'XXXX' Revenue Code (DI22) value should be greater than $0 if the Plan Sponsor (or plan) made a bundled payment to a provider for health benefit items or services.

All claim detail lines submitted to substantiate a “bundled claim detail line” (i.e. a claim line with the value of XXXX (four X’s) in the Revenue Code (DI22) field) must have a From Date of Service (DI07) and a To Date of Service (DI08) that is within the date range specified in the bundled claim detail line.

Correct Example: For Claim Number (HI04) 123, there is at least one detail line following Claim Line Item Numbers (DI05) 001 and 004 reported for a given claim with Principal ICD Procedure Code (DI16), Revenue Code (DI22), and/or Procedure Code (D123), and an Item Plan Paid Amount (DI31) equal to $0 after an 'XXXX' and before the next 'XXXX' or the end of claim detail lines. In addition, Claim Line Item Numbers 002, 003, and 005 have a From Date of Service (DI07) and a To Date of Service (DI08) that is within the date range specified in the bundled claim detail lines (Claim Line Item Numbers 001 and 004).

Incorrect Example: For Claim Number (HI04) 123, there is no detail line following Claim Line Item Number (DI05) 004, with Principal ICD Procedure Code (DI16), Revenue Code (DI22), and/or Procedure Code (D123) and an Item Plan Paid Amount (DI31) equal to $0, after the last 'XXXX' detail line and before the end of claim detail lines for the given claim. In addition, the dates in the From Date of Service (DI07) and the To Date of Service (DI08) fields in Claim Line Item Numbers 002 and 003 are outside the date range specified in the bundled claim detail line (Claim Line Item Number 001).

Professional Claims

For a professional claim, to report health benefit items or services for which payment by the Plan Sponsor (or plan) to a provider was bundled, the value 'XXXXX' must be used in the Procedure Code (DP09) field and reported on a separate claim line detail record. Also, one or more subsequent claim line detail records, immediately following the claim detail record with the value 'XXXXX' in the Procedure Code (DP09) field, must include the details about the items and/or services that were paid by the plan in the bundled payment. Do so by making the Item Plan Paid Amount (DP24) equal to $0 AND by populating the Procedure Code (DP09) field with a valid value. Without a specific Procedure Code (DP09) on a subsequent detail line to identify the bundled service(s), the claim, and the entire Claim List, will be rejected.

Multiple claim detail lines may have the 'XXXXX' Procedure Code (DP09); however, the 'XXXX' must be followed by a claim detail line with a valid Procedure Code (DP09) along with an Item Plan Paid Amount (DP24) equal to $0 before the next bundled ('XXXXX' Procedure Code) line.

The Item Plan Paid Amount (DP24) for the claim detail line with the 'XXXXX' Procedure Code (DP09) value should be greater than $0 if the Plan Sponsor (or plan) made a bundled payment to a provider for health benefit items or services.

All claim detail lines submitted to substantiate a “bundled claim detail line” (i.e. a claim line with the value of XXXXX (five X’s) in the Procedure Code (DP09) field) must have a From Date of Service (DP06) and a To Date of Service (DP07) that is within the date range specified in the bundled claim detail line.

Correct Example: For Claim Number (HP04) 123, there is at least one detail line following Claim Line Item Numbers (DP05) 001 and 004 with Procedure Code (DP09) and an Item Plan Paid Amount (DP24) equal to $0 after an 'XXXXX' detail line and before the next detail line with a Procedure Code (DP09) of 'XXXXX' or the end of claim detail lines. In addition, Claim Line Item Numbers 002, 003, 005, and 006 have a From Date of Service (DP06) and To Date of Service (DP07) that is within the date range specified in the bundled claim detail lines (Claim Line Item Numbers 001 and 004).

Incorrect Example: For Claim Number (DP04) 123, there is no detail line following Claim Line Item Number (DP05) 004, with Procedure Code (DP09) and an Item Plan Paid Amount (DP24) equal to $0, after the last 'XXXXX' detail line and before the end of claim detail lines for the given claim.  In addition, the dates in the From Date of Service (DP06) and the To Date of Service (DP07) for Claim Line Item Numbers 002 and 003 are outside the date range specified in the bundled claim detail line (Claim Line Item Number 001).

Answer ID: 1100-23
Date Posted: 07/18/2011      Last Updated:12/23/2011

ANSWER: Yes. If cost adjustments are attributed to a given individual (i.e. a specific Member ID/Member Group ID combination) and the claims were incurred for such individual both before and on or after June 1, 2010, then both the CA and CB Cost Adjustment Record Layouts must be used to report the amount of cost adjustments. This is important since the claims incurred before June 1, 2010 are not eligible for reimbursement, but, nonetheless, cost adjustment amounts may still affect such paid claim amounts. Cost adjustments associated with claims incurred by the plan prior to June 1, 2010 for an individual, must be reported using the CB Cost Adjustment Record Layout. Cost adjustments associated with claims incurred by the plan on or after June 1, 2010 for an individual, must be reported using the CA Cost Adjustment Record Layout.

Answer ID: 1100-24
Date Posted: 07/18/2011

ANSWER: No. DRGs will not be accepted as a valid value for the Revenue Code field. A DRG does not sufficiently identify all of the health benefit items and services provided to ensure it is eligible for reimbursement under the ERRP.

The reporting of bundled claims is acceptable as outlined in the Common Questions.

Answer ID: 1100-25
Date Posted: 07/18/2011

ANSWER: Because the amount of claims incurred before June 1, 2010 that exceed $15,000 are not eligible for reimbursement, pre-6/1/2010 claim amounts that exceed the $15,000 Cost Threshold should be entered in the Limit Reduction field on the Cost Data Entry Edit web page in the SWS.

For claims incurred prior to June 1, 2010, eligible claim detail records up to and including the claim detail record that causes the costs for an individual to exceed the Cost Threshold, must be reported on the Claim List. Entering the amounts in excess of the Cost Threshold in the Limit Reduction field will enable the cost amounts reported on the Claim List to match the Summary Cost Data reported in the SWS.

Example:

Assume Plan Sponsor has incurred claims for a given Early Retiree totaling $25,000 prior to June 1, 2010. On or after 6/1/2010 an additional $11,000 in claims is incurred by the Plan Sponsor for the same individual. (Assume that no post point-of-sale price concessions and therefore no Cost Adjustment records are involved, and that no Costs Paid By Early Retiree are involved.)

The Cost Paid by Plan amount, for the Early Retiree is $36,000 ($25,000 + $11,000). The dollar amount that should be reported in the Limit Reduction field in the ERRP SWS is $10,000. ($25,000 claims incurred prior to June 1, 2010, minus the cost threshold of $15,000 ).

Answer ID: H1100-26
Date Posted: 07/18/2011

ANSWER: Yes, there is nothing in the ERRP Secure Website to prevent you from submitting a new Claim List; however, the ERRP Center recommends you wait to submit a new Claim List until after you have received feedback on the previously submitted list. Waiting for feedback from the ERRP Center will give you a better understanding of what may cause a Claim List to be invalid and prevent errors in future Claim List submissions.

Answer ID: 1100-27
Date Posted: 08/19/2011

ANSWER: No. Only submit claims for individuals who have met or exceeded the cost threshold. Additionally, in this scenario, the subscriber would not be included in the Total Number of Unique Retirees included in the File Trailer record. This number should only include a count of the unique individuals within the Claim List.

Answer ID: 1100-28
Date Posted: 08/19/2011

ANSWER: If you receive an email that your reimbursement request was canceled because the Claim List associated with a Reimbursement Request was invalid, carefully review the error codes against the submitted Claim List to find the claim detail line(s) and field(s) in error. Correct all errors on the Claim List as applicable and only submit the Claim List if you are reasonably confident it is error-free.

After revising and resubmitting the Claim List, update the Summary Cost Data, and then submit a new, corrected reimbursement request. Any new reimbursement request will be reviewed by ERRP in the order it is received, based on the date of the new request. Note: Before submitting a revised Claim List, ensure the corresponding Early Retiree List is not about to expire. Each Early Retiree List expires 90 days after its corresponding Early Retiree List Response File is created by the ERRP Center.

Answer ID: 1100-29
Date Posted: 08/19/2011

ANSWER: Yes. All claim types from all claims processors should be combined into one Claim List since thresholds and limits must be applied at the unique person identifier level. Remember that every Claim List submission is a full file replacement. All claim records are required in one Claim List, for example professional, institutional, pharmacy, cost adjustment (if applicable), and file trailer.

Answer ID: 1100-30
Date Posted: 08/19/2011

ANSWER: Yes. Such rebates are considered price concessions.

Answer ID: 1100-31
Date Posted: 08/19/2011

ANSWER: No. If for example the Service Location Zip Code field value is '00212' and it is submitted to ERRP Center in the Claim List as '212', the Claim List will be rejected since '212' is not a valid zip code. When using applications such as Excel, numeric and alphanumeric fields must be formatted as text to eliminate the truncation of numbers. (This should be noted for the Revenue Code field as well.)

Answer ID: 1100-32
Date Posted: 08/19/2011