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  1. QRDA Issue Tracker
  2. QRDA-323

QRDA I files requirning Medicare HIC numbers

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    • Resolution: Done
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      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
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      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

      We are posting this question as the QRDA-250 ticket is closed. We would like to clarify the solution posted for QRDA-250. The solution is listed below for reference:

      "For EP reporting, HIC number is required (SHALL) for Medicare patient, QRDA 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."

      We are working on a solution for EP/EH regarding the response stated above, regarding QRDA files, and trying to determine which Medicare SOP payer codes would be rejected without a HIC number. Based on the questions, not all Medicare managed care and non-managed care patients have a HIC number. We have also found patients with a Medicare Code of 19 (Medicare Other) do not always have a HIC number. Could you verify that all 'children' codes require a HIC number? The list of codes is provided for reference.

      Your assistance is greatly appreciated!

      Parent SOP Payer Code:
      1 MEDICARE
      Medicare Children SOP Payer Codes:
      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

            yanheras Yan Heras
            mhinterberg@ofmq.com Michelle Hinterberg (Inactive)
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