This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable regulations for complete andcurrent information about the requirements that apply to them.

FM Payment Processing 2020Early Year Payment Reminder, 1095 -A Reminder, and Payment Dispute Guidance Updates

November 16, 2020

Division of Financial Transfers and Operations (DFTO)

Session Guidelines

• This is a 60-minute webinar session

• For questions regarding content, submit inquiries

to fmcc@cms.hhs.gov

• For questions regarding logistics and registration,

contact the Registrar at: (800) 257-9520

2

Agenda

• Early Year Payment Reminder

• 1095-A Reminder

• Payment Dispute Guidance

3

Early Year Payment Reminder

No Upper Bound Adjustments for Plan Year 2021

• CMS will not be providing Federally-facilitated Exchange (FFE) Issuers with upper-bound

adjustments for Policy-Based Payments in Plan Year 2021

• This means that all Advance Payments of the Premium Tax Credit (APTC) and User Fee

(UF) charges for Plan Year 2021 starting in January 2021 will be based solely on policies

effectuated on the FFE

• To ensure accurate payment calculation, Issuers should make every effort to update new

Plan Year 2021 policies as quickly as possible to reflect effectuation once binder payment

has been received

– Issuers should submit effectuation transactions via Inbound 834 (IC834) transaction

by Friday, December 11th to ensure processing ahead of the January payment

extract to be taken at 3:00 a.m. EST on Wednesday, December 16th

– The first opportunity to apply effectuations via Enrollment Reconciliation will occur at

the end of December and would be reflected in the February payment cycle

• Inbound Reconciliation (RCNI1) Files will be due for the first production

reconciliation cycle by 3:00 p.m. EST on Wednesday, December 30th

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1095-A Reminder

1095-A Reminder

• This is a friendly reminder to make sure your 2020 enrollment information is accurate and

up-to-date for the upcoming release of 1095-As to your members

– Check all remaining initial enrollments on your RCNI file

• Submit effectuations or cancellations to CMS through enrollment reconciliation or

the dispute process

• Check all remaining I and F flags on your RCNO file

• Make updates to your enrollment system or submit disputes or reconcile with

CMS to make corrections as necessary

– Submit timely grace period expiration terminations to CMS through inbound 834s or

enrollment reconciliation

– Submit Enrollment Disputes to correct any remaining enrollment reconciliation issues

by 12/21/2020

– Submit enrollment reconciliation updates in the December RCNI by 12/22/2020

Errors in 2020 enrollment that remain in January will lead to 1095-A errors,

consumer disputes, research costs for CMS and issuers, and a poor customer

experience for your members

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Payment Dispute Guidance

Payment Dispute Guidance

I. Payment Dispute Reminders

II. Filling in Matching Values for Payment Disputes

III. AM Approval for Prior Year Disputes

IV. New Detail Codes:

1. FV112

V. Common Errors:

1. PD594 & PY594

2. FV9

VI. zONE Publications

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Payment Dispute Reminders

• Please submit your Payment Disputes!

– Submit a Payment Dispute for any record perceived to be incorrect

– Issuers may submit large volumes of Payment Disputes without impeding processing time

• Updated: Payment Dispute Support

– Please consult the detail code verbiage to identify the correct support team for assistance resolving rejected Payment Disputes. Use the contact information provided to submit any questions regarding rejected Payment Disputes

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Fill ing in Matching Values for Payment Disputes

• The Payment Dispute team recommends that issuers only fill in the financial value fields when there is a discrepancy greater than $.02.NOTE: Issuers should populate the Federally-facilitated Marketplace (FFM) date fields on any dispute that contains at least one (1) FFM financial value even when the dates are not in dispute

• Disputes containing matching issuer and FFM Premium, APTC, Cost-sharing Reduction (CSR), or UF fields may require manual analysis, resulting in additional processing time

• For example, in this dispute for an incorrect APTC, the issuer correctly:

– Includes the disputed FFM APTC amount, FFM Start Date, and FFM End Date

– Does not include values in the other fields that contain matching financial values

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AM Approval for Prior Year Disputes

• As of 10/01/2020, issuers must acquire approval from their Account Manager (AM) before submitting Enrollment and Payment Disputes for 2016 and 2019NOTE: Issuers do not need AM approval for disputes associated to HICS cases

• AM approval waivers will remain in effect until 01/04/2021 for 2017 disputes and until 02/04/2021 for 2018 disputes

• Issuers must complete the new Issuer/AM Approval Form for Prior Year Disputes to request approval.NOTE: Aside from the new form, the AM approval process has not changed

• Issuers with questions regarding the new AM Approval Form should consult the new Prior Year Dispute Approval Master Guidance v5.0. The new version contains detailed information on the new AM Approval Form and processes involved in submitting prior year disputes

• Both the new AM Approval Form and the Prior Year Dispute Approval Master Guidance v5.0 are available on zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation

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New Detail Code: FV112

• New Detail Code: FV112

• FV112 applies to any dispute in which Enrollment Reconciliation & Resolution (ER&R) is unable to process the requested update because the dispute is associated to a HIOS and coverage year that is part of an active CMS audit

– FV112 Issuer Action: After the conclusion of the audit, review the current FFM policy information. If necessary, submit a new dispute to ER&R for processing

• FV112 results in disposition code R7: Suppressed Issuer

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Common Errors: PD594 and PY594

• ER&R has seen a significant number of Payment Disputes receive the PD594 orPY594 detail codes, which result in the disposition codes R6 or R10

• The PD594 and PY594 detail codes indicate that the disputed record is an uneven record, with one (1) or more field-level discrepancies flagged for the issuer or FFM to update within the enrollment group. These records will have a record-level E or P flag in the current RCNO file

• To allow for the FFM updates to occur, issuers must align the uneven records by either:

– Modifying the next RCNI submission to match the FFM records contained in the Pre-Audit file

– Submitting an Enrollment Dispute to update the FFM data and reconcile the discrepancy causing the unmatched or uneven records

14

Common Errors: FV9

• ER&R has noticed many Payment Disputes receiving the FV9 detail code, which results in the disposition code R3: FFM Fields on Form do not Match PPR/HIX 820

• Disputes receive the FV9 detail code when an issuer disputes an unexpected or incorrect payment but the PPR/HIX 820 report does not contain a record of a payment that matches the disputed data

• Most disputes that receive the FV9 detail code have the wrong Payment Cycle Month on the dispute

• In order to avoid the FV9 detail code, issuers must ensure that the Payment Cycle Month on the dispute matches the month in the Policy-Based Transition Month field in the PPR file and not necessarily the month that the coverage took place

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Common Errors: FV9 ( C o n t i n u e d )

• Here is an example of a dispute that will receive an FV9 detail code and the

relevant PPR:

• Other fields that can result in FV9 detail codes include:

– HIOS ID

– Exchange Assigned Policy ID

– Coverage Period Start Date (FFM)

– Coverage Period End Date (FFM)

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zONE Publications

• Issuers can review the updated documentation on CMS zONE at https://zone.cms.gov/document/enrollment-resolution-and-reconciliation

• The Disposition and Detail Code List v29 includes the new and updated detail codes presented in the previous slides as well as updates to detail codes to reference SEED

• The updated UIR 101 and Disputes 101 slide decks contain the new slides presented on the Enrollment Ops training series

• The Combined Enrollment and Payment TRG v11.0 contains updated guidance for Enrollment Dispute Form v13, Enrollment Blockers, and references to SEED

• The HICS Direct Dispute Master Guidance v3.0 and HICS Direct Dispute Cheat Sheet contain clarifications about Enrollment Blocker cases

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Questions?

To submit or withdraw questions by phone:

• 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.

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Appendix

ACCESS TO CMSzONE

Step 1: CMS Secure Portal Registration Process:(Pre-requisite to CM SzONE Access)

1. Register for access at CMS Secure Portal Here: https://portal.cms.gov/

2. Click on “New User Registration” under CMS Secure Portal

3. Complete information and create User ID and Passw ord

Step 2: CMS zONE Access Request:1. Log in at https://portal.cms.gov/ w ith your CMS Secure Portal credentials

2. Click on “Request Access Now ”

3. Scroll dow n the page to f ind “zONE” and click on “Request Access”

4. Complete information and w ait for confirmation email

5. Once confirmation email is received, user may log-in to CMSzONE

Step 3: CMSzONE Private issuer Community Access:(After being granted CM S zONE access)

1. Log into zONE; click on the Communities tab

2. Click Browse Private Communities

3. Click Issuer Community – Private

4. Click Join Community

5. Provide explanation of w hy you need access to this community; Include:

• name and contact information

• issuer POC contacts

• specific work for issuer (i.e. fill out QHP templates, processing 834’s, etc.)

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User Access Quick GuideA copy of the comprehensive User Access Quick Guide is posted on zONE @:

https://zone.cms.gov/document/zone-end-user-access-quick-guide (pre-log in required to access zONE links)

Reference Documents

• 2019 Manual Adjustments Guidance:

https://www.regtap.info/uploads/library/FMPP_TemporaryManualAdjustmentPBP_12

0718_5CR_120718.pdf

• Enrollment, Payment Processing, and Invoicing New Issuer Training (FFEs):

https://www.regtap.info/uploads/library/FMPP_FFE_NewIssuerSlides_110519_V1_5

CR_110819.pdf

• Early Year Payment Adjustment Issuer Slides:

https://zone.cms.gov/document/november-9th-2018-issuer-meeting-slides

• Financial Management Overview for 2020 SBE Issuers:

https://www.regtap.info/uploads/library/FMPP_SBE_NewIssuerSlides_110519_V1_5

CR_110719.pdf

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Reference Documents ( C o n t i n u e d )

• SBE Issuer Information page (all of the following documents are availableon

this page): https://zone.cms.gov/wiki/sbm-Issuer-information

• SBE Issuer ICD: https://zone.cms.gov/document/sbe-Issuer-icd

• SBE PBP Transition Guide: https://zone.cms.gov/document/sbe-Issuer-

transition-guide

• SBE Issuer PBP FAQ: https://zone.cms.gov/document/policy-based-

payments-transition-faq

• CSR Operations FAQ: https://zone.cms.gov/document/csr-operations-

faq

• Monthly Batch Cycle Calendars: https://zone.cms.gov/wiki/sbm-Issuer-

information

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Reference Documents ( C o n t i n u e d )

• Issuer Dispute Form: https://zone.cms.gov/document/Issuer-dispute-form

• Enrollment and Payment Files Chart: https://zone.cms.gov/document/sbm-

pbp-files-chart

• Managed File Transfers (MFT) Thin Client Help Guide:

https://www.regtap.info/reg_librarye.php?i=1778

• CMS Individual Market HIX 820 X12 Scenarios:

https://zone.cms.gov/document/cms-individual-market-hix-820-x12-

scenarios

• Payee Information Report (Function code: PNR) for Payee:

https://zone.cms.gov/document/payee-information-report

• Temporary Manual Adjustment Scenarios:

https://zone.cms.gov/document/temporary-manual-adjustments-scenarios

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Contacting FMCC

When contacting the FMCC, issuers

should include their five (5)-digit Health

Insurance Oversight System (HIOS) IDand their seven (7)-character Payee ID,

along with their request.

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Acronyms

Acronym Definition

DSH/HUB Data Services Hub

EFT Electronic File Transfer/Electronic FundsTransfer

EPS Enrollment and Payment System

FFE Federally-facilitated Exchange

FMCC Financial Management Coordination Center

HIOS Health Insurance Oversight System

HIX Health Insurance Exchange

PBP Policy-based Payments

PNR Payee Information Report

PPR Preliminary Payment Report

PSV Pipe-separated value

SBE State-based Exchange

SHOP Small Business Health Options Program

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Resources

Resources

Inbound 834 Process (CMS zOne Dedicated Page):

• Production Overview, Technical Specifications, Reporting

• For further assistance, please contact: inbound834@bah.com

• Enrollment Reconciliation:

• For further assistance, please contact: recon_issuer_support@bah.com

Dispute submission:

• Resources

• Payment dispute form:

• https://zone.cms.gov/system/files/documents/ft_ppr_820_dispute_form_002.xls_x

• Combined Enrollment and Payment Dispute Technical Reference Guide:

https://www.regtap.info/reg_librarye.php?i=2664

• For further assistance, please contact the ER&R Support Center at

errsupportcenter@cognosante.com or (855) 591-7113

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Combined Enrollment and Payment Dispute Technical Reference Guide

• The Combined Enrollment and 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:

• https://www.regtap.info/reg_librarye.php?i=2664

• https://zone.cms.gov/system/files/documents/combined_e

nrollment_and_payment_disputes_trg_v3.2.docx

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Resource Links

Resource Resource Link

Centers for Medicare & Medicaid Services

(CMS)

https://www.cms.gov/

U.S. Department of Health & Human Services

(HHS)

https://www.hhs.gov/

The Center for Consumer Information &

Insurance Oversight (CCIIO) web page

https://www.cms.gov/cciio

Consumer website on Health Reform https://www.healthcare.gov

ASC X12Store https://store.x12.org/store/health-insurance-exchanges

Registration for Technical Assistance Portal

(REGTAP) - presentations, FAQs

https://www.REGTAP.info

CMS zONE – reference material https://zone.cms.gov

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Inquiry Tracking and Management System (ITMS)

Stakeholders can submit inquiries to

https://www.REGTAP.info through ITMS.

Select “Submit an Inquiry” or to view submitted inquiries select ‘My Inquiries’ from My Dashboard.

Note: Enter only one (1) question per submission.

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FAQ Database on REGTAP

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.

FAQs Database is available at

www.REGTAP.info

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Closing Remarks