New NPI verification process for eligibility inquiries set to begin

After years of delays, the process for verifying eligibility will soon change for healthcare providers throughout the country. CMS is migrating hospital, home healthcare, hospice and skilled nursing (Part A) eligibility inquiries from the Common Working File system (CWF) to the HIPAA Eligibility Transaction System (HETS) in the fall. After that time, providers will no longer be able to access CWF to verify eligibility. The transition will not impact access to the CWF for claims management.

Healthcare providers who want to verify Part A Medicare eligibility benefits will be required to use a National Provider Identifier (NPI) that is registered in the Medicare Provider Enrollment and Chain/Ownership System (PECOS) database. As part of the eligibility process, these eligibility applications will verify that the NPI used on the inquiry is present in the Medicare PECOS database.

What to expect with the new NPI verification process

Whether you work in an acute or post-acute setting, the change means that inquiries made with NPIs NOT present in the Medicare PECOS database will fail to return Medicare eligibility data. To avoid verification disruption, it’s critical that you review the PECOS status for any NPIs currently used by your organization. If your NPIs are not currently registered with PECOS, update that information accordingly. Additional information on PECOS and how to register your NPI can be found here.

What if your organization uses HETS, or uses both HETS and CWF for eligibility verification? If you’re already using HETS, there’s nothing you need to do. If you’re currently using both systems, you should start using HETS exclusively.

How we got here

CMS first signaled plans to discontinue eligibility checks through CWF in December 2012, announcing that HETS would be the single source for this data. After receiving feedback about and later resolving the differences in data returned from the two systems and the one-year limit to HETS historical searches, CMS is now moving forward with the transition to one system.

Inovalon has you covered

As was the case in previous CMS transitions, Inovalon is well prepared to make sure healthcare providers experience no disruption.

For ABILITY EASE^® Medicare, ABILITY CHOICE^® Medicare Eligibility and ABILITY COMPLETE^® customers, the transition is a non-event. Providers can continue to verify eligibility in CWF until CMS requires the move to HETS. From there, Inovalon will manage the transition to HETS to ensure a seamless transition for the customer. It’s one of the many ways we help simplify complexity for our customers.

For more information on how our RCM solutions help providers streamline their front- and back-end revenue workflows, while keeping up with regulatory changes, check out all our revenue cycle management software.