Eli's Hospice Insider

Published on Mon Oct 19, 2015 PDF

The devil is in the details when it comes to entering beneficiary data.

Starting in January under hospice payment reform, knowing how long your hospice patients have been on the benefit will be key to accurately knowing how much you’ll get paid. But you won’t be able to access that information unless you enter their name in the HETS system correctly.

Problem #1: CMS’s HIPAA Eligibility Transaction System “will not return data when all fields entered do not match the beneficiary’s data as it is maintained in HETS,” HHH Medicare Administrative Contractor Palmetto GBA warns on its website. “You may enter data into optional fields, but these fields are not required to receive a valid Medicare beneficiary eligibility benefit response. If data entered into an optional field does not match the beneficiary’s data maintained in CMS’ HETS system, eligibility data will not be returned on the eligibility response tabs.”

Solution #1: Enter required field data only to avoid delays. The optional fields are “Subscriber Name Suffix,” “Subscriber Gender,” and “Optional Fields for Requesting Historical Data Using Date Range,” CMS says in its HETS UI User Guide at www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/HETS-UI-User-Guide.pdf .

Problem #2: “If the beneficiary has a hyphenated name or a name suffix, it may need to be entered differently in your OPS inquiry than how it appears on the Medicare card. The HETS system does not allow special characters,” Palmetto notes.

Solution #2: Try hyphenated names in HETS with a space or as a combined single name, Palmetto suggests.

Problem #3: Name suffixes may be listed in HETS as part of the last name or as in the separate “Subscriber Name Suffix” field.

Solution #3: “If the beneficiary’s name contains a suffix, please try entering it in the ‘Subscriber’s Last Name’ field first when performing the eligibility inquiry in OPS,” Palmetto instructs.