4
Medicare providers, suppliers, or their authorized billing agents (including
clearinghouses and third party vendors) can register as HETS users. Providers can either
connect to HETS directly or through their clearinghouses and third-party eligibility
verification products/software.
HETS users submit HIPAA-compliant 270 eligibility request files over a secure connection,
and receive 271 response files that address the status of eligibility (active or inactive) and
patient financial responsibility for Medicare Part A and Part B. For more information, visit
the HETS website.
Q13: What happened to the QMB Remittance Advice changes from October 2017?
A13: On October 2, 2017, the Provider Remittance (RA) and the Medicare Summary Notice
(MSN) for QMB claims began identifying the QMB status of beneficiaries’ and reflecting
their zero cost-sharing liability. However, the RA changes caused unforeseen issues
affecting the processing of QMB cost-sharing claims by States and other payers
secondary to Medicare. To address these unanticipated consequences, beginning
December 8, 2017, CMS temporarily suspended the QMB system changes.
In March 2018 – MACs begin issuing replacement RAs through non-monetary mass
adjustments for Qualified Medicare Beneficiary (QMB) claims paid after October 2 and
up to December 31, 2017, that have not been voided or replaced. Providers can use the
replacement RAs to resubmit Medicaid QMB cost-sharing claims that states initially
failed to pay due to the RA changes. Read MLN Matters Article MM10494 for more
information.
In July 2018, CMS will reintroduce QMB information in the RA in a way that avoids
disrupting the claims processing systems of secondary payers. For more information,
see Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program MLN
Matters Article.
Q14: How will the RA reflect a beneficiary’s QMB status starting July 2, 2018?
A14: Starting July 2, 2018, for original Medicare claims, the RA will reintroduce revised
QMB-specific Alert Remittance Advice Remark Codes (RARC).
• N781 – Alert: Patient is a Medicaid/Qualified Medicare Beneficiary. Review your
records for any wrongfully collected deductible. This amount may be billed to a
subsequent payer.
• N782 – Alert: Patient is a Medicaid/Qualified Medicare Beneficiary. Review your
records for any wrongfully collected coinsurance. This amount may be billed to a
subsequent payer.
The RAs will retain the display of monetary values for deductible and coinsurance
amounts in conjunction with Group Code “PR” and associated Claim Adjustment Group