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  1. QRDA Issue Tracker
  2. QRDA-250

How do we identify medicare patient in QRDA1

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    • Icon: QRDA-I Standard QRDA-I Standard
    • Resolution: Done
    • Icon: Minor Minor
    • None
    • QRDA I implementation not clear. Submission may be impacted.
    • Medhost Inc
    • Satej
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      [6/28/2016] update:
      Thank you for your patience. We have received confirmation from the Division of Medicare Enrollment Coordination that all Medicare beneficiaries are assigned a HIC number. Therefore, for the 2016 reporting period, the PQRS system will continue to perform the same validation performed for the 2015 reporting period, which is:
      The PQRS system will reject QRDA-I files where any payer includes any Medicare SOP code (all SOP codes listed below), but they don’t provide a HIC number:
      1 MEDICARE
      11 Medicare (Managed Care)
          111 Medicare HMO
          112 Medicare PPO
          113 Medicare POS
          119 Medicare Managed Care Other
      12 Medicare (Non-managed Care)
          121 Medicare FFS
          122 Medicare Drug Benefit
          123 Medicare Medical Savings Account (MSA)
          129 Medicare Non-managed Care Other
      19 Medicare Other


      [4/3/2016] For EP reporting, HIC number is required (SHALL) for Medicare patient, QRDA-I file will be rejected if no HIC number is submitted for Medicare patient. the PQRS system validates whether a patient is a Medicare patient based on the SOP code submitted in the Patient Characteristic Payer template, if the SOP code is 1 or code for any of the child concept of Medicare, then the HIC number is required.

      For HQR, HIC number SHOULD be submitted if a patient is Medicare patient, the HQR system does not currently validates using the SOP code.
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      [6/28/2016] update: Thank you for your patience. We have received confirmation from the Division of Medicare Enrollment Coordination that all Medicare beneficiaries are assigned a HIC number. Therefore, for the 2016 reporting period, the PQRS system will continue to perform the same validation performed for the 2015 reporting period, which is: The PQRS system will reject QRDA-I files where any payer includes any Medicare SOP code (all SOP codes listed below), but they don’t provide a HIC number: 1 MEDICARE 11 Medicare (Managed Care)     111 Medicare HMO     112 Medicare PPO     113 Medicare POS     119 Medicare Managed Care Other 12 Medicare (Non-managed Care)     121 Medicare FFS     122 Medicare Drug Benefit     123 Medicare Medical Savings Account (MSA)     129 Medicare Non-managed Care Other 19 Medicare Other [4/3/2016] For EP reporting, HIC number is required (SHALL) for Medicare patient, QRDA-I file will be rejected if no HIC number is submitted for Medicare patient. the PQRS system validates whether a patient is a Medicare patient based on the SOP code submitted in the Patient Characteristic Payer template, if the SOP code is 1 or code for any of the child concept of Medicare, then the HIC number is required. For HQR, HIC number SHOULD be submitted if a patient is Medicare patient, the HQR system does not currently validates using the SOP code.

      QRDA I should have HIC# if patient is Medicare. I have two question on this :

      Question#1
      How does CMS identifies a medicare patient from SOP?
      In other words, which SOP# should have HIC# in QRDA.

      For medicare managed care and non-managed care, we may not have HIC# but private policy#.

      Question#2
      If despite having medicare patient, if we are not able to provide HIC#, is MRN or history# sufficient?

            yanheras Yan Heras
            satejprabhu Satej Ramesh Prabhu (Inactive)
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              Created:
              Updated:
              Resolved: