Financial Management Overview for New 2017 FFM Issuers November 28, 2016 Financial Management WWW.REGTAP.INFO
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Payment Processing Overview and Reporting (HIX 820), 9/9/13November
28, 2016
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Payments Overview Vendor Management EDI Onboarding and Testing Enrollment Data Alignment and Policy- Based Payments Enrollment Data Alignment 834 Outbound and Inbound Transactions Enrollment Reconciliation Overview
The Monthly Payment Cycle and Policy-based Payments Payments and Invoicing Preliminary Payment Report and HIX 820 Discrepancy Reporting December and January Recon and Payment Calendars
• 2017 Checklist for New FFM Issuers
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Webinar Purpose
The purpose of this webinar is to provide new 2017 FFM Issuers with a complete overview of the end-to-end Enrollment, Payment and Invoicing Process.
Associations New 2017 Federally- Facilitated Marketplace (FFM) Issuers New 2017 FFM Stand-Alone Dental Plans (SADP)
New 2017 Vendors/Third Party Administrators (TPAs) and Clearinghouses New 2017 FFM Small Business Health Options Program (SHOP) Issuers
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• Receipt of accurate and timely payment of APTC, CSR, and payment of User Fees involves four (4) major steps: – Onboarding: Prior to the 2017, ensure connectivity and correct
information has been filed with CMS through HIOS, Vendor Management, and the EDI onboarding processes.
– Enrollment data alignment: Exchange of enrollment transactions and files with CMS to align Issuer and CMS records of enrollment.
– Receive Policy-Based Payment and Review Payment Reports through CMS’s monthly payment process.
– Submit Disputes to CMS for any identified discrepancies.
Onboarding Overview
HIOS Overview
The Health Insurance Oversight System (HIOS) is the central web portal for Issuers to access modules used by CMS to collect and store information from health insurance companies. HIOS is the portal to the
Financial Management Module, which allows Issuers to create Payee Groups and Financial Information Forms (FIFs).
HIOS stores Tax ID Number (TIN) and Legal Business Name (LBN) information for registered health insurance companies.
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Health insurance companies must complete the Vendor Management Process to create a Payee Group and provide CMS with banking and billing information in order to receive payments/invoices.
Health insurance companies create a Payee Group through the Financial Management Module in HIOS.
Each month, the Payee Group will receive a consolidated payment and payment report (HIX 820).
Most new 2017 Issuers have already completed this process. CMS will be reaching out to any Issuers who have not completed this process.
Vendor Management Key Points
Payee Group Configuration
• A Payee Group is a set of one (1) or more Issuers that have the same TIN.
• Each Payee Group must contain all Issuers under one (1) TIN. For example, if a company has three (3) Issuers with the same TIN, they will only be allowed to establish one (1) Payee group for all three (3) Issuers.
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Issuers may find detailed information regarding the Vendor Management process by clicking the link below to view the April 17, 2015 Vendor Management webinar slides: o https://www.regtap.info/uploads/library
FT_3R_VM_slides_041715_5CR_042715.pdf Additionally, Issuers may search the REGTAP Library at https://www.REGTAP.info under the Payments-Payee Groups program area for additional supporting documents related to the Vendor Management Process.
Additional Information
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The HUB will facilitate the exchange of Enrollment based, PPR and HIX 820 transactions from CMS to Payees and trading partners. In order to receive HIX 820 transactions, Trading Partners (i.e., Payee Groups, SBMs or their designees) must register and conduct a successful test (onboard) with the HUB. Issuers link their Payee Group ID to a registered or new Trading Partner ID and onboard with the HUB. All Issuers and their Business Associate (clearinghouse or TPA) who receive the payment transactions on their behalf must complete the onboarding process prior to January 2017. Issuers and SBMs who want to receive any other payment related transactions are required to submit an onboarding form. Issuers may reach out to the [email protected] mailbox for any additional information related to form submission.
Trading Partner Registration Process
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During the Spring of 2016 CMS teams presented Issuer Onboarding 101 material at the Plan Management event (March 2016).
Detailed information related to the completion of the CMS Marketplace EDI Registration Form process was presented. The link to the information is found in the REGTAP resource Library at: New Issuer Onboarding Presentation delivered at April 2016 Plan Management event: o https://www.regtap.info/uploads/library/QHPOnsite_IssuerOnboardi
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All FFM Issuers in the Individual Market receive APTC, CSR and User Fee policy-level payment and charges using the process known as Policy-based Payments (PBP). PBP makes APTC and CSR payments to Issuers, and collects FFM User Fees, based on effectuated enrollment information in the FFM system. Therefore, the exchange of information about consumer enrollment between CMS and FFM Issuers drives payment accuracy.
FFM Payment Overview
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SBMs and their Issuers are still being transitioned to Policy-based Payments and are currently paid through a Manual Payment Process.
CMS Exchanges enrollment information with FFM Issuers through two (2) major processes:
1. Outbound and Inbound 834 Transactions, exchanged daily
2. Monthly enrollment reconciliation
Enrollment Data Alignment Overview
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Initial enrollment information is sent for each enrollee or enrollment group to the Qualified Health Plan (QHP) or Qualified Dental Plan (QDP) Issuer via an 834 transaction (Outbound 834 transaction). Once the enrollee makes the payment to the selected QHP Issuer for the Individual Marketplace, the Issuer adds the effectuated policy into their system with the correct benefit, plan, etc. Once the enrollment processes are complete and coverage is effectuated, the QHP Issuer sends an 834 transaction (Inbound 834 transaction) to the FFM confirming enrollment status. CMS uses the 834 enrollment transaction to collect data on enrollment status and Issuer Assigned IDs for Issuer Assigned Policy ID, Issuer Assigned Subscriber ID, Issuer Assigned Member ID and Last Paid Date.
834 Transaction Key Points
An Outbound 834 Transaction is created by the FFM and sent to the QHP Issuer after an individual or group has submitted an application and has been determined eligible and selected a QHP. Upon receipt of the Issuer’s EDI platform, the Issuer is to generate the TA1 and 999 Acknowledgment transactions which are returned to the FFM EDI platform within 48 hours.
The EDI team will perform outreach if the acknowledgment timer exceeds 48 hours.
Outbound 834 Transaction
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An Inbound 834 Transaction is created by the QHP or QDP Issuer and sent to the Data Services Hub (the HUB) once the Initial Enrollment transaction is confirmed (effectuated or canceled). Inbound 834 Transactions update FFM insurance policies in near “real-time” as Issuers report a policy’s change in payment (or non-payment) status.
Inbound 834 Transaction
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Except where specified by the 005010X22 TR3, Issuers must re- transmit all information transmitted on the Outbound 834 Transaction.
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https://zone.cms.gov/document/m834-application-data Note: Today tweaked baseline August scenarios (suffixes ending with “1” and “2”)
M834 Test Scenarios Spreadsheet (all 30 at a glance) (Please note the initial effective dates show 1/1, in contrast to test data set where initial effective dates are for summer months, reflecting current system non-OE period) https://zone.cms.gov/document/maintenance-834-test-scenarios
M834 Operations Manual https://zone.cms.gov/document/federally-facilitated-marketplace-maintenance-834-operations-manual
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834 Resources
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CMS initiated the Enrollment Pre-audit process in December 2013 to provide Issuers with a comprehensive view of enrollment data from the FFM perspective. As Issuers have found this comprehensive view of FFM enrollment data useful on a regular basis, CMS has continued to produce and distribute these files and will do so in 2017.
This Pre-audit File also represents the effectuated enrollments for which Issuers will receive Policy-based Payments (as applicable) for the subsequent month.
The Pre-audit File will *not* be in the EDI 834 format; it will be a pipe-delimited flat file. All Pre-audit Files are year-specific; Pre-audit Files for 2017 will only contain data pertaining to enrollments effective January 1, 2017 through December 31, 2017. This includes effectuated, uneffectuated and cancelled enrollment records. There are typically additional files distributed with the Pre-audit File each month which supplement the file with additional details on certain records.
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To ensure consistency between FFM and Issuer enrollment data throughout Plan Year 2017, CMS will be initiating monthly reconciliation of 2017 enrollment data early in December 2016.
Per regulatory requirement, Issuers must reconcile enrollment data with CMS on a monthly basis. Issuers will submit an inbound Reconciliation file for each Trading Partner ID during each monthly cycle.
CMS will perform an initial validation on the Issuer file, match Issuer enrollment records to FFM records, and compare on a field-by-field basis for matched records.
Results of matching and field-by-field comparison are sent to Issuers via the outbound Reconciliation (RCNO1&) File.
Last Name Benefit Start Date Applied APTC Amount
DOB Benefit End Date APTC Effective / End Dates
Gender Effectuation Status CSR Advance Payment Amount
SSN Exchange-Assigned Policy ID CSR Effective / End Dates
Subscriber Indicator Exchange-Assigned Subscriber ID
Total Premium Amount
Relationship Code Exchange-Assigned Member ID Total Premium Effective / End Dates
Residential Address Issuer-Assigned Policy ID Paid Through Date
Mailing Address Issuer-Assigned Subscriber ID
Issuer-Assigned Member ID
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ust_2016_0.pdf
Outbound Reconciliation File Specification: https://zone.cms.gov/system/files/documents/outbound_enrollment_reconciliation_file_specification_v3_32_aug
If you have questions on Enrollment Reconciliation, please send them to the Help Desk ([email protected]) with the subject line “RECONCILIATION – QUESTION.”
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The high-level monthly process for making payments includes: • 15th of month prior: Snapshot of the FFM used as basis for the
month’s payment • CMS calculates Policy-based Payments of APTC, CSR, and User
Fees and aggregates with any other payments (e.g., RA, RI); nets payments and charges
• ~11th of Payment Month: Issuers receive any invoices • ~15th of Payment Month: Preliminary Payment Reports sent to
Issuers • ~20-22 of Payment Month: Issuers receive payment • By the End of Payment Month: Issuers receive HIX 820
the FFM.
FFM aggregates enrollment and payment data
from the EPS to make payments to Issuers and net APTC/CSR payments and FFM User Fees
charges.
information to Treasury and
Treasury issues payments to
balance receive Demand Letters. Issuers remit all
outstanding balances through
transaction with all payments and invoicing
data.
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On a monthly basis, payments and charges for Marketplace programs are aggregated and netted at the Payee Group level and sent to the CMS accounting system for processing. Payees with a net positive balance will receive one (1) lump-sum payment through Electronic Funds Transfer (EFT). Payees with a net negative balance will receive an Invoice, which is mailed to the Payee Group’s billing address. The Payee Group uses the Invoice to pay the amount(s) owed through Pay.gov.
Payments and Invoicing Key Points
Issuers may find detailed information regarding the Collections and Invoicing Process by clicking the link below to view the January 30, 2015 Collections and Invoicing webinar slides: o https://www.regtap.info/uploads/library/FT_CollectionsInvoicing_slides_013015_5CR_051215.pdf
For questions about the payment process, Issuers may also search the REGTAP Library under the Payments–Monthly Processing Cycle and Payments–Remitting Amounts Due program areas for supporting documents.
Issuers should send questions related to their Invoice to the Invoice and Collections Team at [email protected].
Issuers are encouraged to review their preliminary payment reports (PPRs) and HIX 820 for detailed monthly program totals, questions about reading these reports may be referred to [email protected].
Questions pertaining to the Enrollment & Payment Data Workbook may be referred to [email protected].
Additional Information
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In the middle of each month, Payees will receive a Preliminary Payment Report (PPR).
The PPR is a pipe-separated file and contains all the policy- level payment details for a Payee.
All Issuer Payees will receive one (1) PPR near the middle of the month that corresponds to HIX 820 transaction(s) provided near the end of the same month. This will include Program level Payments as well.
Issuers will receive one (1) PPR with all their policy-level details and program level details, regardless of payment amount or number of policies.
Preliminary Payment Reports
A sample Preliminary Payment Report will be posted to REGTAP
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• The PPR will be sent via EFT to the same routing location that is setup for the current EFT transmissions for the States or the Payees.
• The function code for the PPRs will be TBD. • The file names will be in the following format:
o TradingPartnerID.FunctionCode.Date.Time o For example: 1234567.TBD.D150529.T124846968.P
• CMS does not expect a TA1/999 or any electronic acknowledgement for the PPRs.
Coverage Period Start Date
Coverage Period End Date
HIX 820 Key Points
The HIX 820 is an X12 remittance advice transaction which includes all of the information provided on the preliminary payment report, as well as the Treasury EFT Trace Number and the date the payment was sent to the Payees bank account.
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The HIX 820 is a separate transaction from the payment transfer and all CMS HIX 820s are outbound only (i.e., from CMS to Payee Groups).
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CMS uses the HIX 820 to communicate remittance information for the following types of payments and charges related to Marketplace functions:
Advance Payment of the Premium Tax Credits (APTCs) Cost Sharing Reductions (CSRs) FFM Individual and SHOP User Fees
o Reinsurance, Risk Adjustment and Risk Corridors (if applicable)
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Payees will receive one (1) HIX 820 per month per EFT: The HIX 820 includes policy-level information including any program-level payments, adjustments and other remittance information.
A Payee will receive two (2) separate HIX 820s and two (2) separate EFT payments if:
The Payee is set to receive a payment of $100 million or more; and/or
• The Payee has one (1) million effectuated policies or more in a month.
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• Issuers may find additional information on the HIX 820 Transaction and transition to Policy-based Payments by clicking the links below: o FM Policy-based Payments Overview and HIX 820 Testing and Implementation slides –
https://www.regtap.info/uploads/library/FT_HIX820_SeriesI_slides_042215_5CR_05191 5.pdf
o FM Policy-based Payments HIX 820 Testing and Scenarios slides – https://www.regtap.info/uploads/library/FT_HIX820_slides_052715_5CR_060415.pdf
• Additionally, Issuers may search the Payments – Remittance Message (HIX 820) program area at https://www.REGTAP.info in the REGTAP Library for additional supporting documents related to the HIX 820 transaction.
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Once Payees receive Preliminary Payment Reports, they respond with any identified discrepancies. When a discrepancy is identified, Issuers use an Excel template to submit discrepancies to the discrepancy resolution contractor.
CMS, in coordination with the Enrollment Resolution & Reconciliation (ER&R) contractor, investigates the discrepancies and provides a response to Issuers letting them know the status of each dispute. Any changes to a payment or charge will reflect in a future month’s Preliminary Payment Report and HIX 820 transaction.
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Monthly, Issuers receive two (2) files with the current cycle payment data.
The Preliminary Payment Report (PPR) informs Issuers which policies will have payments or payment adjustments applied.
The HIX 820 provides remittance advice to Issuers after the payments have been processed.
Issuers should use the PPR and HIX 820 to verify receipt of PBP. If Issuers identify a missing, unexpected, or incorrect PBP when reviewing the PPR or HIX 820, submit a PPR- 820 Dispute Form to request CMS investigation.
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• Issuers can dispute six (6) items on the Payment Dispute Form. – Benefit Start Date – Benefit End Date – Total Premium Amount – Advanced Premium Tax Credit (APTC) – Cost Sharing Reduction (CSR) – User Fee (UF)
• The most current version of the PPR-820 Dispute Form, version 2.0, is on CMS zONE at: https://zone.cms.gov/document/ppr-820-disputes- page.
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• CMS assigns both a disposition code and up to five (5) detail codes to each dispute.
• A disposition code describes the current condition of the payment dispute so that Issuers know the time frame they can expect to see a change in status or if they need to take further action to reconcile the discrepancy.
• Detail codes provide an additional level of detail which explain why the disposition code was applied and any applicable next steps.
• The latest version of the Payment Disposition and Detail Code List is available on zONE at: https://zone.cms.gov/document/ppr-820-disputes-page
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Issuers receive several reports which allow them to monitor dispute outcome and status.
The Response File • CMS sends this file within one (1) business day of receiving
the dispute. • The Response File reports the results of each dispute and
includes: o The CMS Dispute Control Number o A Disposition Code o Up to five (5) applicable Detail Codes
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• Issuers receive a Semi-Monthly Report for disputes that have had a change in disposition status since the preceding Semi-Monthly Issuer Report.
• CMS distributes the report twice a month, on the 1st and 15th or the first business day after if the 1st or 15th falls on a weekend or holiday
• Issuers should use their own Issuer supplied values from the submission in combination with CMS supplied values to trace disputes.
• The “Payment Disputes” tab of the Semi-Monthly Issuer Report includes an explanation for specific dispute dispositions.
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If you are having trouble submitting a file or locating a response file or Semi- Monthly report, call or email the ER&R Support Center at:
• (855) 591-7113 • [email protected] • Please supply File Control Number (Issuer) (H1) from submission when initiating
these inquiries Please contact the FMCC (Financial Management Coordination Center) help desk at [email protected] with any:
• Questions or concerns around the Payment Dispute process • Requests for technical assistance
The Technical Resource Guide (TRG) for Payments contains a wealth of knowledge. Issuers are highly encouraged to read through the guide to better understand how to effectively utilize Payment Disputes. The TRG is located at:
Issuers can access the PPR-820 Dispute Form v2 at the following links: https://www.regtap.info/reg_librarye.php?i=1352 https://zone.cms.gov/document/ppr-820-disputes-page
The latest Dispute Disposition and Detail Code List is found at: https://www.regtap.info/uploads/library/FT_DetailCodeList_110716_
5CR_111016.pdf https://zone.cms.gov/document/ppr-820-disputes-page
REGTAP • CMS provides webinars each Monday from 2:00 p.m. to 3:30 p.m. ET
to share information and technical guidance related to PBP and the Dispute Reporting Process.
• Issuers should register at https://www.regtap.info/ in order to receive notice of these webinars and access updated materials.
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Register with ARDX for Enrollment webinars and Payment Processing webinars and attend scheduled webinars. Attend weekly enrollment recon / inbound 834 call (Thursday @ 12:30 p.m. ET) and Issuer Technical workgroup (Tuesday @ 3 p.m. ET) and prepare to send monthly reconciliation files and daily 834 transactions. Review documents on REGTAP paying particular attention to the payment processing section that includes:
Payment processing calendar • •
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Pay.Gov Payment dispute process
Establish Payee Group using the HIOS Vendor Management Module. If a Trading partner agreement is already in place, new function codes will need to be added for payment processing EFT data exchange. If no Trading partner agreement is in. place, EFT onboarding is required.
2017 Checklist for New FFM Issuers
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http://www.regtap.info/
WWW.REGTAP.INFO
Questions?
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Dial *# (star-pound) on your phone’s keypad to ask a question
Dial *# (star-pound) on your phone’s keypad to withdraw your question
To submit questions by webinar: Type your question in the text box under the ‘Q&A’ tab 64
Key Payment Activities November December January
SBM Issuer Workbooks Submission Window Oct. 17th –21st Nov. 16th–22nd Dec. 16th–21st
Vendor Management Module Open Nov. 11th –24th Dec. 11th–24th Jan. 11th–24th
Initial Invoice sent to Issuers Nov. 10th Dec. 13th Jan. 9th
Preliminary Payment Reports sent to Issuers Nov. 10th–14th Dec. 9th–13th Jan. 12th–17th
Treasury issues payments to Issuers Nov. 21st Dec. 21st Jan. 23rd
HIX 820 Payment transactions sent to Issuers Nov. 30th Dec. 30th Jan. 31st
Key Dates
Inbound 834 Process (CMS zOne Dedicated Page): Production Overview, Technical Specifications, Reporting For further assistance, please contact:
Enrollment Reconciliation: o
o Dispute submission:
Payment dispute form: https://zone.cms.gov/document/enrollment-resolution-and- reconciliation-dispute-form Payment dispute Technical Reference Guide: https://zone.cms.gov/document/ppr- 820-disputes-page
For further assistance, please contact the ER&R Support Center at [email protected] or (855) 591-7113
Vendor Management Reminders
Payee group information is used to direct program payments to your organization and provides the designated contact information in the event that CMS has a need to contact you. Maintaining your corporate billing address ensures that invoices will be delivered timely avoiding the accrual of interest and late fees.
• The Financial Management (FM) module is open from the 11th through the 24th of each month and closes on the 25th of each month through the 10th of the following month during the payment processing execution. All updates made to your payee group require internal approval from your organization prior to CMS having access to review and approve your record. To ensure that updates to your records are accepted and applied in the system, the updates need your approval two (2) business days prior to the 25th of the month.
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If your edits include changes to your banking information, your financial institution is required to fax a Bank Verification Letter (BVL) directly to CMS at 301-492-4746 to allow CMS will approve these updates. In the interim, your record is in a state of limbo and payments will not be processed. You can reach the CMS Vendor Management Team at [email protected].
Vendor Management Reminders (continued)
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CMS directs Issuers to contact the Federal Enrollment and Payment System (FEPS) Helpdesk with technical questions or issues. Issuers can contact the FEPS Helpdesk at the [email protected] email address.
CMS directs Issuers to contact the Marketplace Payments Team with questions related to the Manual Payment Process. Issuers can contact Marketplace Payments at the [email protected] email address.
CMS directs Issuers to contact the Financial Management Coordination Center (FMCC) with questions regarding the PBP process. Issuers can contact the FMCC at the [email protected] email address.
CMS directs Issuers to contact the Enrollment Reconciliation and Resolution (ER&R) contractor with questions regarding the discrepancy reporting process, as well with dispute form submissions. Issuers can contact the ER&R contractor at the [email protected] email address.
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• Issuers with multiple RA payments or charges can distinguish between them by referring to the Invoice Number using the convention below.
• RA Invoice Number Example: I14VA160112345001
o Digit 1: Program and Market Designator (I) o Digits 2-3: Program Year (14) o Digits 4-5: State Code (VA) o Digits 6-9: Year and Month (1601) o Digits 10-14: Issuer ID (12345) o Digits 15-17: Transaction Sequential Counter (001)
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• Program and Market Designator (Digit 1) Key: – Risk Adjustment Individual – I – Risk Adjustment Small Group – L – Risk Adjustment Catastrophic – T – Risk Adjustment Merged – M – Risk Adjustment Default Charge Individual – N – Risk Adjustment Default Charge Small Group – O – Risk Adjustment Default Charge Catastrophic – H – Risk Adjustment Default Charge Merged - B
PPR and HIX 820 File Issues
Please follow the escalation path below for issues with File Transfer Protocol (FTP) or locating the monthly Preliminary Payment Report (PPR) and HIX 820 payment files:
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Email: [email protected]
HIX 820 Contact the CMS Help Desk and request a Remedy Ticket for the issue. The Help Desk will assign the ticket to the appropriate support team who will reach out to Issuers to resolve.
Email: [email protected]
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Additional information related to the PBP transition is available in the Registration for Technical Assistance Portal (REGTAP) Library at the following links:
FM 2015 – 2016 Issuer Transition Guide, Version 4.4 PBP Temporary Adjustment Reconciliation Methodology May 2, 2016 Payment Bulletin PBP May Payment Back-out Example Workbook
Documents Available on REGTAP
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EDI Electronic Data Interchange
FFM Federally-facilitated Marketplace
HIX Health Insurance Exchange
o File submission.
Contacting FMCC
When contacting the FMCC, Issuers should include their five (5)-digit Health Insurance Oversight System (HIOS) ID and their seven (7)-character Payee ID, along with their request.
• The Payment Dispute Technical Reference Guide (TRG) provides guidelines for Issuers regarding how to submit Payment Disputes.
• Issuers can access the TRG at the following links: o https://www.regtap.info/uploads/library/FT_TRG_v1_
5CR_101416.pdf o https://zone.cms.gov/document/ppr-820-disputes-
U.S. Department of Health & Human Services (HHS)
http://www.hhs.gov/
The Center for Consumer Information & Insurance Oversight (CCIIO) web page
http://www.cms.gov/cciio
ASC X12 Store http://store.x12.org/store/health- insurance-exchanges
Registration for Technical Assistance Portal (REGTAP) - presentations, FAQs
Document Location
Additional Materials for FM Payment Processing I are available in the REGTAP Library at https://www.REGTAP.info
Under Program Area, select “Payment Processing (X12 HIX 820)”
Stakeholders can submit inquiries to ITMS at https://www.REGTAP.info
Select “Submit an Inquiry” from My Dashboard.
FAQ Database is available at https://www.regtap.info/
The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary Categories, Benefit Year, Retired and Current FAQs and Publish Date.
Onboarding Overview
HIOS Overview
Vendor Management
Enrollment Data Alignment and Policy-based Payments
FFM Payment Overview
Enrollment Data Alignment
834 Transaction Key Points
Enrollment Data Reconciliation Concepts
The Monthly Payment Cycle and Policy-based Payments
FFM Policy-based Payments Overview
Payments and Invoicing
Slide Number 37
Preliminary Payment Reports
Pipe-separated File Example
Payment Disputes - Outcomes
The Response File
Slide Number 60
Slide Number 61
Questions?
RA on Invoices, PPRs and HIX 820s (continued)
PPR and HIX 820 File Issues
Additional Information
FAQ Database on REGTAP
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Payments Overview Vendor Management EDI Onboarding and Testing Enrollment Data Alignment and Policy- Based Payments Enrollment Data Alignment 834 Outbound and Inbound Transactions Enrollment Reconciliation Overview
The Monthly Payment Cycle and Policy-based Payments Payments and Invoicing Preliminary Payment Report and HIX 820 Discrepancy Reporting December and January Recon and Payment Calendars
• 2017 Checklist for New FFM Issuers
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Webinar Purpose
The purpose of this webinar is to provide new 2017 FFM Issuers with a complete overview of the end-to-end Enrollment, Payment and Invoicing Process.
Associations New 2017 Federally- Facilitated Marketplace (FFM) Issuers New 2017 FFM Stand-Alone Dental Plans (SADP)
New 2017 Vendors/Third Party Administrators (TPAs) and Clearinghouses New 2017 FFM Small Business Health Options Program (SHOP) Issuers
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• Receipt of accurate and timely payment of APTC, CSR, and payment of User Fees involves four (4) major steps: – Onboarding: Prior to the 2017, ensure connectivity and correct
information has been filed with CMS through HIOS, Vendor Management, and the EDI onboarding processes.
– Enrollment data alignment: Exchange of enrollment transactions and files with CMS to align Issuer and CMS records of enrollment.
– Receive Policy-Based Payment and Review Payment Reports through CMS’s monthly payment process.
– Submit Disputes to CMS for any identified discrepancies.
Onboarding Overview
HIOS Overview
The Health Insurance Oversight System (HIOS) is the central web portal for Issuers to access modules used by CMS to collect and store information from health insurance companies. HIOS is the portal to the
Financial Management Module, which allows Issuers to create Payee Groups and Financial Information Forms (FIFs).
HIOS stores Tax ID Number (TIN) and Legal Business Name (LBN) information for registered health insurance companies.
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Health insurance companies must complete the Vendor Management Process to create a Payee Group and provide CMS with banking and billing information in order to receive payments/invoices.
Health insurance companies create a Payee Group through the Financial Management Module in HIOS.
Each month, the Payee Group will receive a consolidated payment and payment report (HIX 820).
Most new 2017 Issuers have already completed this process. CMS will be reaching out to any Issuers who have not completed this process.
Vendor Management Key Points
Payee Group Configuration
• A Payee Group is a set of one (1) or more Issuers that have the same TIN.
• Each Payee Group must contain all Issuers under one (1) TIN. For example, if a company has three (3) Issuers with the same TIN, they will only be allowed to establish one (1) Payee group for all three (3) Issuers.
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Issuers may find detailed information regarding the Vendor Management process by clicking the link below to view the April 17, 2015 Vendor Management webinar slides: o https://www.regtap.info/uploads/library
FT_3R_VM_slides_041715_5CR_042715.pdf Additionally, Issuers may search the REGTAP Library at https://www.REGTAP.info under the Payments-Payee Groups program area for additional supporting documents related to the Vendor Management Process.
Additional Information
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The HUB will facilitate the exchange of Enrollment based, PPR and HIX 820 transactions from CMS to Payees and trading partners. In order to receive HIX 820 transactions, Trading Partners (i.e., Payee Groups, SBMs or their designees) must register and conduct a successful test (onboard) with the HUB. Issuers link their Payee Group ID to a registered or new Trading Partner ID and onboard with the HUB. All Issuers and their Business Associate (clearinghouse or TPA) who receive the payment transactions on their behalf must complete the onboarding process prior to January 2017. Issuers and SBMs who want to receive any other payment related transactions are required to submit an onboarding form. Issuers may reach out to the [email protected] mailbox for any additional information related to form submission.
Trading Partner Registration Process
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During the Spring of 2016 CMS teams presented Issuer Onboarding 101 material at the Plan Management event (March 2016).
Detailed information related to the completion of the CMS Marketplace EDI Registration Form process was presented. The link to the information is found in the REGTAP resource Library at: New Issuer Onboarding Presentation delivered at April 2016 Plan Management event: o https://www.regtap.info/uploads/library/QHPOnsite_IssuerOnboardi
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All FFM Issuers in the Individual Market receive APTC, CSR and User Fee policy-level payment and charges using the process known as Policy-based Payments (PBP). PBP makes APTC and CSR payments to Issuers, and collects FFM User Fees, based on effectuated enrollment information in the FFM system. Therefore, the exchange of information about consumer enrollment between CMS and FFM Issuers drives payment accuracy.
FFM Payment Overview
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SBMs and their Issuers are still being transitioned to Policy-based Payments and are currently paid through a Manual Payment Process.
CMS Exchanges enrollment information with FFM Issuers through two (2) major processes:
1. Outbound and Inbound 834 Transactions, exchanged daily
2. Monthly enrollment reconciliation
Enrollment Data Alignment Overview
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Initial enrollment information is sent for each enrollee or enrollment group to the Qualified Health Plan (QHP) or Qualified Dental Plan (QDP) Issuer via an 834 transaction (Outbound 834 transaction). Once the enrollee makes the payment to the selected QHP Issuer for the Individual Marketplace, the Issuer adds the effectuated policy into their system with the correct benefit, plan, etc. Once the enrollment processes are complete and coverage is effectuated, the QHP Issuer sends an 834 transaction (Inbound 834 transaction) to the FFM confirming enrollment status. CMS uses the 834 enrollment transaction to collect data on enrollment status and Issuer Assigned IDs for Issuer Assigned Policy ID, Issuer Assigned Subscriber ID, Issuer Assigned Member ID and Last Paid Date.
834 Transaction Key Points
An Outbound 834 Transaction is created by the FFM and sent to the QHP Issuer after an individual or group has submitted an application and has been determined eligible and selected a QHP. Upon receipt of the Issuer’s EDI platform, the Issuer is to generate the TA1 and 999 Acknowledgment transactions which are returned to the FFM EDI platform within 48 hours.
The EDI team will perform outreach if the acknowledgment timer exceeds 48 hours.
Outbound 834 Transaction
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An Inbound 834 Transaction is created by the QHP or QDP Issuer and sent to the Data Services Hub (the HUB) once the Initial Enrollment transaction is confirmed (effectuated or canceled). Inbound 834 Transactions update FFM insurance policies in near “real-time” as Issuers report a policy’s change in payment (or non-payment) status.
Inbound 834 Transaction
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Except where specified by the 005010X22 TR3, Issuers must re- transmit all information transmitted on the Outbound 834 Transaction.
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https://zone.cms.gov/document/m834-application-data Note: Today tweaked baseline August scenarios (suffixes ending with “1” and “2”)
M834 Test Scenarios Spreadsheet (all 30 at a glance) (Please note the initial effective dates show 1/1, in contrast to test data set where initial effective dates are for summer months, reflecting current system non-OE period) https://zone.cms.gov/document/maintenance-834-test-scenarios
M834 Operations Manual https://zone.cms.gov/document/federally-facilitated-marketplace-maintenance-834-operations-manual
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834 Resources
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CMS initiated the Enrollment Pre-audit process in December 2013 to provide Issuers with a comprehensive view of enrollment data from the FFM perspective. As Issuers have found this comprehensive view of FFM enrollment data useful on a regular basis, CMS has continued to produce and distribute these files and will do so in 2017.
This Pre-audit File also represents the effectuated enrollments for which Issuers will receive Policy-based Payments (as applicable) for the subsequent month.
The Pre-audit File will *not* be in the EDI 834 format; it will be a pipe-delimited flat file. All Pre-audit Files are year-specific; Pre-audit Files for 2017 will only contain data pertaining to enrollments effective January 1, 2017 through December 31, 2017. This includes effectuated, uneffectuated and cancelled enrollment records. There are typically additional files distributed with the Pre-audit File each month which supplement the file with additional details on certain records.
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To ensure consistency between FFM and Issuer enrollment data throughout Plan Year 2017, CMS will be initiating monthly reconciliation of 2017 enrollment data early in December 2016.
Per regulatory requirement, Issuers must reconcile enrollment data with CMS on a monthly basis. Issuers will submit an inbound Reconciliation file for each Trading Partner ID during each monthly cycle.
CMS will perform an initial validation on the Issuer file, match Issuer enrollment records to FFM records, and compare on a field-by-field basis for matched records.
Results of matching and field-by-field comparison are sent to Issuers via the outbound Reconciliation (RCNO1&) File.
Last Name Benefit Start Date Applied APTC Amount
DOB Benefit End Date APTC Effective / End Dates
Gender Effectuation Status CSR Advance Payment Amount
SSN Exchange-Assigned Policy ID CSR Effective / End Dates
Subscriber Indicator Exchange-Assigned Subscriber ID
Total Premium Amount
Relationship Code Exchange-Assigned Member ID Total Premium Effective / End Dates
Residential Address Issuer-Assigned Policy ID Paid Through Date
Mailing Address Issuer-Assigned Subscriber ID
Issuer-Assigned Member ID
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ust_2016_0.pdf
Outbound Reconciliation File Specification: https://zone.cms.gov/system/files/documents/outbound_enrollment_reconciliation_file_specification_v3_32_aug
If you have questions on Enrollment Reconciliation, please send them to the Help Desk ([email protected]) with the subject line “RECONCILIATION – QUESTION.”
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The high-level monthly process for making payments includes: • 15th of month prior: Snapshot of the FFM used as basis for the
month’s payment • CMS calculates Policy-based Payments of APTC, CSR, and User
Fees and aggregates with any other payments (e.g., RA, RI); nets payments and charges
• ~11th of Payment Month: Issuers receive any invoices • ~15th of Payment Month: Preliminary Payment Reports sent to
Issuers • ~20-22 of Payment Month: Issuers receive payment • By the End of Payment Month: Issuers receive HIX 820
the FFM.
FFM aggregates enrollment and payment data
from the EPS to make payments to Issuers and net APTC/CSR payments and FFM User Fees
charges.
information to Treasury and
Treasury issues payments to
balance receive Demand Letters. Issuers remit all
outstanding balances through
transaction with all payments and invoicing
data.
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On a monthly basis, payments and charges for Marketplace programs are aggregated and netted at the Payee Group level and sent to the CMS accounting system for processing. Payees with a net positive balance will receive one (1) lump-sum payment through Electronic Funds Transfer (EFT). Payees with a net negative balance will receive an Invoice, which is mailed to the Payee Group’s billing address. The Payee Group uses the Invoice to pay the amount(s) owed through Pay.gov.
Payments and Invoicing Key Points
Issuers may find detailed information regarding the Collections and Invoicing Process by clicking the link below to view the January 30, 2015 Collections and Invoicing webinar slides: o https://www.regtap.info/uploads/library/FT_CollectionsInvoicing_slides_013015_5CR_051215.pdf
For questions about the payment process, Issuers may also search the REGTAP Library under the Payments–Monthly Processing Cycle and Payments–Remitting Amounts Due program areas for supporting documents.
Issuers should send questions related to their Invoice to the Invoice and Collections Team at [email protected].
Issuers are encouraged to review their preliminary payment reports (PPRs) and HIX 820 for detailed monthly program totals, questions about reading these reports may be referred to [email protected].
Questions pertaining to the Enrollment & Payment Data Workbook may be referred to [email protected].
Additional Information
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In the middle of each month, Payees will receive a Preliminary Payment Report (PPR).
The PPR is a pipe-separated file and contains all the policy- level payment details for a Payee.
All Issuer Payees will receive one (1) PPR near the middle of the month that corresponds to HIX 820 transaction(s) provided near the end of the same month. This will include Program level Payments as well.
Issuers will receive one (1) PPR with all their policy-level details and program level details, regardless of payment amount or number of policies.
Preliminary Payment Reports
A sample Preliminary Payment Report will be posted to REGTAP
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• The PPR will be sent via EFT to the same routing location that is setup for the current EFT transmissions for the States or the Payees.
• The function code for the PPRs will be TBD. • The file names will be in the following format:
o TradingPartnerID.FunctionCode.Date.Time o For example: 1234567.TBD.D150529.T124846968.P
• CMS does not expect a TA1/999 or any electronic acknowledgement for the PPRs.
Coverage Period Start Date
Coverage Period End Date
HIX 820 Key Points
The HIX 820 is an X12 remittance advice transaction which includes all of the information provided on the preliminary payment report, as well as the Treasury EFT Trace Number and the date the payment was sent to the Payees bank account.
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The HIX 820 is a separate transaction from the payment transfer and all CMS HIX 820s are outbound only (i.e., from CMS to Payee Groups).
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CMS uses the HIX 820 to communicate remittance information for the following types of payments and charges related to Marketplace functions:
Advance Payment of the Premium Tax Credits (APTCs) Cost Sharing Reductions (CSRs) FFM Individual and SHOP User Fees
o Reinsurance, Risk Adjustment and Risk Corridors (if applicable)
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Payees will receive one (1) HIX 820 per month per EFT: The HIX 820 includes policy-level information including any program-level payments, adjustments and other remittance information.
A Payee will receive two (2) separate HIX 820s and two (2) separate EFT payments if:
The Payee is set to receive a payment of $100 million or more; and/or
• The Payee has one (1) million effectuated policies or more in a month.
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• Issuers may find additional information on the HIX 820 Transaction and transition to Policy-based Payments by clicking the links below: o FM Policy-based Payments Overview and HIX 820 Testing and Implementation slides –
https://www.regtap.info/uploads/library/FT_HIX820_SeriesI_slides_042215_5CR_05191 5.pdf
o FM Policy-based Payments HIX 820 Testing and Scenarios slides – https://www.regtap.info/uploads/library/FT_HIX820_slides_052715_5CR_060415.pdf
• Additionally, Issuers may search the Payments – Remittance Message (HIX 820) program area at https://www.REGTAP.info in the REGTAP Library for additional supporting documents related to the HIX 820 transaction.
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Once Payees receive Preliminary Payment Reports, they respond with any identified discrepancies. When a discrepancy is identified, Issuers use an Excel template to submit discrepancies to the discrepancy resolution contractor.
CMS, in coordination with the Enrollment Resolution & Reconciliation (ER&R) contractor, investigates the discrepancies and provides a response to Issuers letting them know the status of each dispute. Any changes to a payment or charge will reflect in a future month’s Preliminary Payment Report and HIX 820 transaction.
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Monthly, Issuers receive two (2) files with the current cycle payment data.
The Preliminary Payment Report (PPR) informs Issuers which policies will have payments or payment adjustments applied.
The HIX 820 provides remittance advice to Issuers after the payments have been processed.
Issuers should use the PPR and HIX 820 to verify receipt of PBP. If Issuers identify a missing, unexpected, or incorrect PBP when reviewing the PPR or HIX 820, submit a PPR- 820 Dispute Form to request CMS investigation.
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• Issuers can dispute six (6) items on the Payment Dispute Form. – Benefit Start Date – Benefit End Date – Total Premium Amount – Advanced Premium Tax Credit (APTC) – Cost Sharing Reduction (CSR) – User Fee (UF)
• The most current version of the PPR-820 Dispute Form, version 2.0, is on CMS zONE at: https://zone.cms.gov/document/ppr-820-disputes- page.
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• CMS assigns both a disposition code and up to five (5) detail codes to each dispute.
• A disposition code describes the current condition of the payment dispute so that Issuers know the time frame they can expect to see a change in status or if they need to take further action to reconcile the discrepancy.
• Detail codes provide an additional level of detail which explain why the disposition code was applied and any applicable next steps.
• The latest version of the Payment Disposition and Detail Code List is available on zONE at: https://zone.cms.gov/document/ppr-820-disputes-page
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Issuers receive several reports which allow them to monitor dispute outcome and status.
The Response File • CMS sends this file within one (1) business day of receiving
the dispute. • The Response File reports the results of each dispute and
includes: o The CMS Dispute Control Number o A Disposition Code o Up to five (5) applicable Detail Codes
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• Issuers receive a Semi-Monthly Report for disputes that have had a change in disposition status since the preceding Semi-Monthly Issuer Report.
• CMS distributes the report twice a month, on the 1st and 15th or the first business day after if the 1st or 15th falls on a weekend or holiday
• Issuers should use their own Issuer supplied values from the submission in combination with CMS supplied values to trace disputes.
• The “Payment Disputes” tab of the Semi-Monthly Issuer Report includes an explanation for specific dispute dispositions.
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If you are having trouble submitting a file or locating a response file or Semi- Monthly report, call or email the ER&R Support Center at:
• (855) 591-7113 • [email protected] • Please supply File Control Number (Issuer) (H1) from submission when initiating
these inquiries Please contact the FMCC (Financial Management Coordination Center) help desk at [email protected] with any:
• Questions or concerns around the Payment Dispute process • Requests for technical assistance
The Technical Resource Guide (TRG) for Payments contains a wealth of knowledge. Issuers are highly encouraged to read through the guide to better understand how to effectively utilize Payment Disputes. The TRG is located at:
Issuers can access the PPR-820 Dispute Form v2 at the following links: https://www.regtap.info/reg_librarye.php?i=1352 https://zone.cms.gov/document/ppr-820-disputes-page
The latest Dispute Disposition and Detail Code List is found at: https://www.regtap.info/uploads/library/FT_DetailCodeList_110716_
5CR_111016.pdf https://zone.cms.gov/document/ppr-820-disputes-page
REGTAP • CMS provides webinars each Monday from 2:00 p.m. to 3:30 p.m. ET
to share information and technical guidance related to PBP and the Dispute Reporting Process.
• Issuers should register at https://www.regtap.info/ in order to receive notice of these webinars and access updated materials.
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Register with ARDX for Enrollment webinars and Payment Processing webinars and attend scheduled webinars. Attend weekly enrollment recon / inbound 834 call (Thursday @ 12:30 p.m. ET) and Issuer Technical workgroup (Tuesday @ 3 p.m. ET) and prepare to send monthly reconciliation files and daily 834 transactions. Review documents on REGTAP paying particular attention to the payment processing section that includes:
Payment processing calendar • •
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Pay.Gov Payment dispute process
Establish Payee Group using the HIOS Vendor Management Module. If a Trading partner agreement is already in place, new function codes will need to be added for payment processing EFT data exchange. If no Trading partner agreement is in. place, EFT onboarding is required.
2017 Checklist for New FFM Issuers
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http://www.regtap.info/
WWW.REGTAP.INFO
Questions?
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Dial *# (star-pound) on your phone’s keypad to ask a question
Dial *# (star-pound) on your phone’s keypad to withdraw your question
To submit questions by webinar: Type your question in the text box under the ‘Q&A’ tab 64
Key Payment Activities November December January
SBM Issuer Workbooks Submission Window Oct. 17th –21st Nov. 16th–22nd Dec. 16th–21st
Vendor Management Module Open Nov. 11th –24th Dec. 11th–24th Jan. 11th–24th
Initial Invoice sent to Issuers Nov. 10th Dec. 13th Jan. 9th
Preliminary Payment Reports sent to Issuers Nov. 10th–14th Dec. 9th–13th Jan. 12th–17th
Treasury issues payments to Issuers Nov. 21st Dec. 21st Jan. 23rd
HIX 820 Payment transactions sent to Issuers Nov. 30th Dec. 30th Jan. 31st
Key Dates
Inbound 834 Process (CMS zOne Dedicated Page): Production Overview, Technical Specifications, Reporting For further assistance, please contact:
Enrollment Reconciliation: o
o Dispute submission:
Payment dispute form: https://zone.cms.gov/document/enrollment-resolution-and- reconciliation-dispute-form Payment dispute Technical Reference Guide: https://zone.cms.gov/document/ppr- 820-disputes-page
For further assistance, please contact the ER&R Support Center at [email protected] or (855) 591-7113
Vendor Management Reminders
Payee group information is used to direct program payments to your organization and provides the designated contact information in the event that CMS has a need to contact you. Maintaining your corporate billing address ensures that invoices will be delivered timely avoiding the accrual of interest and late fees.
• The Financial Management (FM) module is open from the 11th through the 24th of each month and closes on the 25th of each month through the 10th of the following month during the payment processing execution. All updates made to your payee group require internal approval from your organization prior to CMS having access to review and approve your record. To ensure that updates to your records are accepted and applied in the system, the updates need your approval two (2) business days prior to the 25th of the month.
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If your edits include changes to your banking information, your financial institution is required to fax a Bank Verification Letter (BVL) directly to CMS at 301-492-4746 to allow CMS will approve these updates. In the interim, your record is in a state of limbo and payments will not be processed. You can reach the CMS Vendor Management Team at [email protected].
Vendor Management Reminders (continued)
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CMS directs Issuers to contact the Federal Enrollment and Payment System (FEPS) Helpdesk with technical questions or issues. Issuers can contact the FEPS Helpdesk at the [email protected] email address.
CMS directs Issuers to contact the Marketplace Payments Team with questions related to the Manual Payment Process. Issuers can contact Marketplace Payments at the [email protected] email address.
CMS directs Issuers to contact the Financial Management Coordination Center (FMCC) with questions regarding the PBP process. Issuers can contact the FMCC at the [email protected] email address.
CMS directs Issuers to contact the Enrollment Reconciliation and Resolution (ER&R) contractor with questions regarding the discrepancy reporting process, as well with dispute form submissions. Issuers can contact the ER&R contractor at the [email protected] email address.
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• Issuers with multiple RA payments or charges can distinguish between them by referring to the Invoice Number using the convention below.
• RA Invoice Number Example: I14VA160112345001
o Digit 1: Program and Market Designator (I) o Digits 2-3: Program Year (14) o Digits 4-5: State Code (VA) o Digits 6-9: Year and Month (1601) o Digits 10-14: Issuer ID (12345) o Digits 15-17: Transaction Sequential Counter (001)
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• Program and Market Designator (Digit 1) Key: – Risk Adjustment Individual – I – Risk Adjustment Small Group – L – Risk Adjustment Catastrophic – T – Risk Adjustment Merged – M – Risk Adjustment Default Charge Individual – N – Risk Adjustment Default Charge Small Group – O – Risk Adjustment Default Charge Catastrophic – H – Risk Adjustment Default Charge Merged - B
PPR and HIX 820 File Issues
Please follow the escalation path below for issues with File Transfer Protocol (FTP) or locating the monthly Preliminary Payment Report (PPR) and HIX 820 payment files:
• o
Email: [email protected]
HIX 820 Contact the CMS Help Desk and request a Remedy Ticket for the issue. The Help Desk will assign the ticket to the appropriate support team who will reach out to Issuers to resolve.
Email: [email protected]
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Additional information related to the PBP transition is available in the Registration for Technical Assistance Portal (REGTAP) Library at the following links:
FM 2015 – 2016 Issuer Transition Guide, Version 4.4 PBP Temporary Adjustment Reconciliation Methodology May 2, 2016 Payment Bulletin PBP May Payment Back-out Example Workbook
Documents Available on REGTAP
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EDI Electronic Data Interchange
FFM Federally-facilitated Marketplace
HIX Health Insurance Exchange
o File submission.
Contacting FMCC
When contacting the FMCC, Issuers should include their five (5)-digit Health Insurance Oversight System (HIOS) ID and their seven (7)-character Payee ID, along with their request.
• The Payment Dispute Technical Reference Guide (TRG) provides guidelines for Issuers regarding how to submit Payment Disputes.
• Issuers can access the TRG at the following links: o https://www.regtap.info/uploads/library/FT_TRG_v1_
5CR_101416.pdf o https://zone.cms.gov/document/ppr-820-disputes-
U.S. Department of Health & Human Services (HHS)
http://www.hhs.gov/
The Center for Consumer Information & Insurance Oversight (CCIIO) web page
http://www.cms.gov/cciio
ASC X12 Store http://store.x12.org/store/health- insurance-exchanges
Registration for Technical Assistance Portal (REGTAP) - presentations, FAQs
Document Location
Additional Materials for FM Payment Processing I are available in the REGTAP Library at https://www.REGTAP.info
Under Program Area, select “Payment Processing (X12 HIX 820)”
Stakeholders can submit inquiries to ITMS at https://www.REGTAP.info
Select “Submit an Inquiry” from My Dashboard.
FAQ Database is available at https://www.regtap.info/
The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary Categories, Benefit Year, Retired and Current FAQs and Publish Date.
Onboarding Overview
HIOS Overview
Vendor Management
Enrollment Data Alignment and Policy-based Payments
FFM Payment Overview
Enrollment Data Alignment
834 Transaction Key Points
Enrollment Data Reconciliation Concepts
The Monthly Payment Cycle and Policy-based Payments
FFM Policy-based Payments Overview
Payments and Invoicing
Slide Number 37
Preliminary Payment Reports
Pipe-separated File Example
Payment Disputes - Outcomes
The Response File
Slide Number 60
Slide Number 61
Questions?
RA on Invoices, PPRs and HIX 820s (continued)
PPR and HIX 820 File Issues
Additional Information
FAQ Database on REGTAP
Related Documents
