PURPOSE:
This Notice will explain the reasoning behind the edit that requires the Beneficiary Name and HIC Number to match the Internal File, and will also explain procedures on how to correct this error.

TEXT:
The Common Working File (CWF) contains Utilization edits which are performed on all incoming claims. The purpose of these edits is to protect the integrity and ensure the accuracy of CWF's Beneficiary Utilization data. Some of these edits specifically require the beneficiary name submitted on a claim match exactly to the name contained on the Master Record, which is accessed based on the HIC Number submitted on the claim. If the name does not match, CWF will send a response that indicates that they cannot find a Beneficiary record for the name and HIC Number combination that was submitted on the claim. If CWF sends this type of response for a claim, Veritus Inc. will reject the claim. This means the claim will finalize on the provider's Remittance Advice as a rejected claim without any Medicare reimbursement. At this point, the only way for the claim to be finally processed would be for the provider to resubmit it as a new claim.

The Medicare Claims Processing System (MCPS), which was previously in use by Veritus Inc. to process Medicare claims, contained a feature known as the 'beneficiary data fill'. If Veritus Inc. had a record on its internal MCPS Beneficiary file that matched the HIC Number submitted on a claim, the beneficiary data fields (Name, Address, Sex, Birthdate) were automatically 'filled' with the data that was contained on the file, regardless of the data that was actually submitted by the provider in these fields. This resolved a lot of the problems providers are now experiencing in the Florida Shared System (FSS) with claims getting Reason Code 30715 for misspelled names, subtitles, order of first and middle names, etc. This also prevented problems at CWF as the data on our internal file was built primarily with CWF data. Therefore, as long as the provider submitted the correct HIC Number, it didn't matter if it submitted the name exactly as it appeared on the CWF Master file because MCPS changed it to be consistent with CWF.

While this process was useful for correcting some of the specific situations noted above (subtitles, misspellings, name order), it caused problems in the instances when providers inadvertently submitted the incorrect HIC Number, i.e., husband's suffix on wife's claim, or transposed digits, etc. In this scenario, MCPS still overlaid all of the beneficiary data using the HIC Number submitted, and sent the claim to CWF. At that point, it became possible for the claim to process in error, causing problems for the beneficiaries, providers and Veritus Inc.

For example, if a provider submitted an incorrect HIC Number for a patient (Beneficiary A) and there was another Medicare beneficiary on our MCPS internal file for whom the submitted HIC Number was the correct HIC Number (Beneficiary B), then MCPS would overlay the beneficiary information on Beneficiary A's claim with data pertaining to Beneficiary B. The name and HIC Number combination would then be internally consistent. Unfortunately, the name and HIC combination on the claim would be for a different person from the patient that had actually received the services, i.e. incorrect. Unless the claim failed other edits in MCPS or at CWF, it became possible for the utilization to post incorrectly to Beneficiary B's record.

Although this situation impacted relatively few claims, it had the effect of sending Medicare Benefit Notices to the wrong individuals. It was a source of beneficiary confusion and occasional allegations of impropriety on the part of providers when beneficiaries received notices of benefits for services they had not received. Providers may not have been aware of the incorrect posting of benefits. Once payment was received by the provider, there was no reason for the provider to monitor the claim. However, the incorrect posting of utilization data did cause problems for Medicare beneficiaries, for the intermediary, and, ultimately, for providers. Once the utilization record at CWF was incorrect, the only way to correct it was to have the provider submit a Cancel/New Bill combination with the corrected information after learning of the error either from a dissatisfied Medicare beneficiary or from the intermediary.

The Reason Code 30715 edit in FSS duplicates the stringent CWF Name and HIC Number editing; however, it is being done up front, prior to CWF so that incorrect Name and HIC Number situations can be corrected by the provider before the claim gets to CWF, preventing the claim from finalizing as a rejected claim. This is not an optional edit in FSS. This is one of the few edits in FSS which is hardcoded. This means it cannot be altered locally or 'turned off' by Veritus Inc., or any other FSS User. Veritus Inc. also cannot reinstate the automatic 'beneficiary data fill' process that was used in MCPS as this would require adding a 'local modification' to the FSS software to accomplish it. The design and architecture of the FSS does not make this a practical or viable option.

Having all of this information as background, the following are procedures that providers can utilize to correct the 30715 Reason Code once it is received:

I. If you submit claims via Tape or PC (Version 004 batch file transfer), claims with 30715 will be sent to the RTP file in DDE. The following describes the correction procedure:

A. If the 30715 is received because the Provider submitted the HIC Number incorrectly;

1. Access the claim on the RTP file.
   
2. Tab to the 'PROCESS NEW HIC' field on Screen 1.
   
3. Enter a 'Y'. The cursor will automatically skip to a second, unlabeled field. Input the correct HIC Number
   here.
   
4. Verify the correct Name information is present; if not, correct it on Screen 1 and Screen 5.
   
5. Press 'PF9' to update and store the claim; the claim will now be stored under the corrected HIC Number.
   

B. If the 30715 is received, and the submitted HIC Number is correct;

1. Access the claim on the RTP file.
   
2. Review the Beneficiary Name information on Screen 1; this data is being pulled directly from the internal Beneficiary file, and what is being used in the editing.
   
3. Review the Beneficiary Name information on Screen 5; this is the Beneficiary name data which was submitted by the Provider on the claim.
   
4. Change the necessary Name fields on Screen 5, so that the Name(s) appear as on Screen 1.
   
5. Press 'PF9' to update and store the claim.

NOTE:
There are instances where the data on the FSS Beneficiary file is incorrect and does not match HIQA. This can occur either due to bad data that was converted to FSS from MCPS, or because the FSS Beneficiary File record was set up incorrectly by a prior claim that was submitted with incorrect beneficiary Name information. If this is the situation, do not change the data to agree with the FSS internal Beneficiary File. Instead, contact your local servicing plan (Western PA providers should call the Provider Servicenter). Internal staff at the plan can correct the FSS Beneficiary File record to reflect the correct name information. The provider will need to monitor the FSS Beneficiary File to determine when the data has been corrected. When the data has been corrected on the FSS internal Beneficiary File, the Provider should follow the applicable procedure described above.

II. If you submit claims via CRT entry in DDE (not CRT correction via the RTP file; this situation is discussed above), claims that receive Reason Code 30715 will suspend to the provider. The following describes the action required:

A. If the 30715 is received because the Provider submitted the HIC Number incorrectly;

There is no correction process available; you must abandon the claim (press 'PF3' to exit claim without saving) and start over.

B. If the 30715 is received, and the submitted HIC Number is correct;

1. Problem is due to an incorrect name and you know what the correct name should be (i.e., keying error):
   

   a. Correct the name data on Screens 1 and 5.
   b. Press 'PF9' to update and store the claim.
   
   

2. Problem is due to an incorrect name and you do not know what the correct name is (data keyed correctly, but 30715 still received):
   

1. You must abandon the claim (press 'PF3' to exit claim without saving).
   
2. Determine the correct name, including the spelling, subtitles, order of names, etc. This can be done either by referencing the beneficiary's Medicare card, or by performing an inquiry for the HIC Number 5
   against the CWF eligibility file (HIQA).
   
3. Return to the Claim Entry Function and rekey the claim in its entirety using the correct name information.
   

NOTE:There are instances where the data on the FSS Beneficiary file is incorrect and does not match HIQA. This can occur either due to bad data that was converted to FSS from MCPS, or because the FSS Beneficiary File record was set up incorrectly by a prior claim that was submitted with incorrect beneficiary Name information. If this is the situation, do not change the data to agree with the FSS internal Beneficiary File. Instead, contact your local servicing plan (Western PA providers should call the Provider Servicenter). Internal staff at the plan can correct the FSS Beneficiary File record to reflect the correct name information. The provider will need to monitor the FSS Beneficiary File to determine when the data has been corrected. When the data has been corrected on the FSS internal Beneficiary File, the Provider can then enter the claim in its entirety via the Claim Entry Function.

III. If you submit claims via paper (Hardcopy UB-92 form), claims that receive Reason Code 30715 will be returned to you as RTP (Return to Provider) claims, and will be reported on the 'MEDICARE RETURN TO PROVIDER (RTP) REPORT'. The following describes the action required:

1. Determine the correct name, including the spelling, subtitles, order of names, etc. This can be done by referencing the beneficiary's Medicare card.
   
2. Resubmit using the correct name information according to the normal procedure for resubmitting RTP claims that contain corrected information (reference CONV UPDATE - 7, dated November 11, 1994).
   

NOTE: There are instances where the data on the FSS Beneficiary file is incorrect and does not match HIQA. This can occur either due to bad data that was converted to FSS from MCPS, or because the FSS Beneficiary File record was set up incorrectly by a prior claim that was submitted with incorrect beneficiary Name information. If you are sure that you have obtained the correct beneficiary name, but keep getting your claim returned for Reason Code 30715, this may be the reason. If you believe this is the situation, contact your local servicing plan (Western PA providers should call the Provider Servicenter). Internal staff at the plan can determine if this the case, and if so, correct the FSS Beneficiary File record to reflect the correct name information. At this point, the Provider can resubmit the claim using the correct name information according to the normal procedure for resubmitting RTP claims that contain corrected information (reference CONV UPDATE - 7, dated November 11, 1994).

EXPECTED IMPACT:
Providers will realize the importance of this edit, and understand that it is not optional. Providers will also be aware of how to correct the 30715 errors when they are received.

Should you have any questions, please contact:

Western Area:	Northeastern Area:	Capital Area:
Provider Servicenter Blue Cross of Western PA (412) 261-9880 or 1-800-242-0346	Professional Affairs Department Blue Cross of Northeastern PA (717) 831-3600	Provider Relations Services Consultant Harrisburg: (717) 541-6207 Allentown: (610) 821-4150

ATTACHMENT(S)
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