CMS Query Procedures

Employee query files should be submitted monthly to CMS to determine which employees are MEDICARE eligible. 

In order to get a response from CMS on the MEDICARE status of an employee CMS requires the following data to be correct:

• 1. Employee SSN - if this does not match the records on file at CMS none of the other data will be used.  This MUST BE correct.

  2. First 6 characters of the employee's LAST NAME - this must match the name on their MEDICARE card.

  3. First character of the employee's FIRST NAME - this must match the name on their MEDICARE card.

  4. Employee's date of birth

  5. Employee's gender

CMS will return and employee's HICN (MEDICARE Number) if the SSN matches their records along with 3 out of the 4 other data elements. CMS will not send any response indicating that there are data errors if the last name, first name, date of birth and gender are incorrect.  The name data must match the information displayed on their MEDICARE card.  No aliases or preferred names should be used in the first and last name fields.

The steps for sending a CMS Query file are:

• 1. Audit employee data in your claims using the following reports from the EDI --> CMS Query Files Menu  ( Menu is shown below)

     1. Query Audit - excel file export that shows claims where one of the requires data elements is missing.

     2. Odd SSN Report - excel file export that shows claims that have the name last name, first name and DOB for the employee but the SSN that is on file in the claims are different.  This report uses the same name criteria that CMS uses for their matching - please note that occasionally there will be twins working for the same company and they both have workers' compensation claims and they will appear on this report.

     3. Odd DOB Report - excel file export that shows claims that have the same SSN but the DOB on file in the claims is different or it shows claims where the employee is less than 18 years old.

     4. Odd Name Report - excel file export that shows claims that have the same SSN but the first and last names are different.

     5. Suspect SSN - excel file export of SSN values that are generally not possible or are too short.

     6. Gender Edit - used to show first names on claims where the gender is missing.  This is an editable grid that will update the gender of those claims with the first name listed if the gender is currently missing when the window is closed.

  2. Generate Query File - After all of the audit reports are clean.

  3. Send Files - will send the query file to CMS for the current RRE. - The response file will take 14 to 21 days to return from CMS.  Account managers are notified that the file has been received and has started processing.  They are also notified by e-mail when processing has finished and the results are ready.  The RRE designee is not notified of anything.

Note: CMS/MEDICARE has a limit of one query file per RRE per Month.  Any additional query files submitted in a month will result in the second file being deleted and an e-mail warning from CMS/MEDICARE.

When the response file is ready to load:

• 1. Select the EDI --> CMS Query Files --> Load Query Results menu (shown below)

  2. Press the "Download" button to get the response file from the CMS SFTP Site. For companies with more than one RRE this will download the result files for all policies that have results that have not been loaded before.

  3. After the result file is listed on the screen shown below press the "Load" button.  This screen will load results for all RRE files listed in the screen that have the "Load" check mark - if you do not wish to load results for a particular RRE - un-check the the box next to the file you do not wish to load. 

  4. After the results are loaded employees with HICN values can be shown on the "Export Eligible Employees" menu selection.

  5. Employee data should be audited periodically using the "Export Employees" menu selection.  This will export all employees with claims to excel in descending age order.  Employee data for employees that are 65 and older that are missing an HICN number should be reviewed to make sure the SSN number, Name, Date of Birth and Gender match their MEDICARE card. 

Note: Not receiving results from CMS on an employee does not mean the employee is not MEDICARE eligible and does not relieve the RRE from determining their MEDICARE status. Attached below is an example form provided by CMS that could be included with the FROI package to help collect their MEDICARE information.  The HICN number can be updated/added in the employee's HRMS record by looking up the employee by using CTRL-H (entering SSN or last name) and using the menu selection "Edit --> Employee data".

Complete information on the CMS query file process can be found in the "MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation USER GUIDE Version 3.1" which can be found at http://www.cms.gov/MandatoryInsRep/03_Liability_Self_No_Fault_Insurance_and_Workers_Compensation.asp