The Annual Full Replacement COB Files Are on Their Way
It’s that time of year again when Part D plans will receive full replacement Coordination of Benefits (COB) files from the Centers for Medicare & Medicaid Services (CMS). The Health Plan Management System (HPMS) memo dated 3/6/15 states that the 2015 Full Replacement COB files will be sent to organizations beginning March 19th. Plans will need to distinguish these files from daily COB notification files by the date of receipt and the file size. Easy enough? Not exactly.
Opportunity to Review and Correct Your Records
The full replacement COB files offer organizations a great opportunity to review their current records, make corrections, and re-sync with CMS. When a Medicare Part D enrollee has other prescription drug coverage, coordination of benefits allows the plans that provide coverage for this same beneficiary to determine each of their payment responsibilities. This process is necessary in order to avoid duplication of payment and to prevent Medicare from paying primary when it is the secondary payer. Unfortunately, many times plans will “just load” the data file when received. This is a very risky decision, as doing so will override information you have already validated with outdated information from CMS. File analytics is a necessary step in the process.
GHG can evaluate your file to determine actions needed, including verification letter mailing
- Part D sponsors are required to notify each beneficiary of other prescription drug coverage information as reflected in the COB file from CMS. The beneficiary should review the information and report back any updates. It’s important to analyze the file and not send out verification letters to members unnecessarily, especially if a letter was recently sent to a member or if the member is terminated. Plans that use the “send letters to all” approach will realize this just overloads your customer service call center.
GHG can assist with the Primary record validation and correction
- Many times erroneous information is on the data file and gets loaded time and again. This can cause multiple problems such as bad COB flags at the Pharmacy Benefit Manager (PBM) or, worse, point-of-sale (POS) issues at the pharmacy which could lead to Complaint Tracking Module complaints (CTMs). It’s important that information submitted to the Electronic Correspondence Referral System (ECRS) is valid, complete, and consistent. Transactions submitted that are incomplete or fail ECRS system edits will be submitted for development, which will place a freeze on the record for up to 100 days.
Unsure where to start? Contact me at ctobin@ghgadvisors.com, and let us help you maneuver through the COB file verification process.
Resources
When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
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