Solutions 

FIR Non Plan of Record

(Proxy Add, Edit and Delete are applicable to Non-Plan of records only)

WHAT IS A NON PLAN OF RECORD?

There are circumstances where it is possible that a Plan has enrolled a beneficiary; however, it is not actually the beneficiary’s Plan of record. These types of enrollments can be classified into two categories as defined below:

1. The beneficiary’s enrollment information was not accepted by CMS

In this scenario, the Plan thinks the beneficiary has enrolled in its Plan. However upon submission of the eligibility file to CMS, CMS rejects the enrollment. In this scenario, CMS will not have a record of the Plan in the CMS eligibility system.

If the Plan has claims that contribute to the beneficiary’s accumulators, the Plan is responsible for reporting that information. Since the CMS Eligibility File will not have a record of the beneficiary’s enrollment in the Plan, the Transaction Facilitator will not include the Plan in any FIR transactions unless the Plan notifies the Transaction Facilitator that they have accumulators for the beneficiary.

The method to notify the facilitator that the Plan should be included in FIR sequences is called a proxy add. The Plan should complete the proxy add form below, encrypt and send the form via secure email to TBTSupport@relayhealth.com

Adding a Non Plan of Record for a Beneficiary (Proxy Add)

2. The beneficiary’s enrollment information was accepted by CMS
a) Another Plan was actually the Plan of record, even though you paid claims for the beneficiary

In this scenario, a Plan’s enrollment has been processed and accepted by CMS; however at some point later another Plan becomes the Plan of record retroactively, thus completely removing the prior Plan’s enrollment and retroactively terminating the Plan back to the effective date.

In this case, the Transaction Facilitator is able to identify the retroactive enrollment for the new Plan, the termination of the prior Plan, and will create an audit off record. The terminated Plan becomes a non Plan of record that will continue to be included in FIR sequences. The terminated Plan continues to be included in the FIR sequences to ensure that any accumulators are transferred to the Plan of record.

When the eligibility for the new Plan of record is received by the Transaction Facilitator an audit off record will be created for the original Plan reflecting the overlapping dates of coverage. If the terminated Plan does not have any accumulators for the beneficiary, they can request that the audit off record be deleted and no longer included in FIR sequences. The Plan should complete the proxy add form below, encrypt and send the form via secure email to TBTSupport@relayhealth.com.

Deleting a Non Plan of Record for a Beneficiary(Proxy Delete)

Note: If a proxy delete request form is submitted for a beneficiary where the last FIR contains accumulator in the response from the requesting Plan, the delete will not be performed. The last FIR response provided by the requesting Plan must not contain any accumulators.

b) The beneficiary’s Plan has not changed, however the PBP and either the BIN, PCN (or both) associated with the beneficiary’s eligibility has changed retroactively.

This would mean that the old BIN or PCN was active at some time even though a new BIN or PCN has retroactively replaced it. Since it is possible that some claims may have paid under the old BIN or PCN, an audit off record is created and the Plan must determine whether or not the old BIN or PCN should be included in FIR transactions. If the Plan has automatically transferred the balances under the new BIN or PCN, then the Plan should proxy delete all audit off records created with the old BIN or PCN.

Plans should also note that BIN or PCN changes not associated with a Contract ID change do not create multiple rows of eligibility in the MARx system. When looking at MARx only the most current change will be reflected.

Deleting a Non Plan of Record for a Beneficiary(Proxy Delete)

Note: If a proxy delete request form is submitted for a beneficiary where the last FIR contains accumulator in the response from the requesting Plan, the delete will not be performed. The last FIR response provided by the requesting Plan must not contain any accumulators.

Editing 4Rx data (Proxy Edit) for a Non Plan of Record

There are situations where 4Rx information for a non-Plan of record is incorrect. This may occur because the:

  • eligibility originally approved by CMS and then retroactively terminated was incorrect
  • 4Rx provided on a Proxy Add request was incorrect

Since the non Plan of record is not in the CMS eligibility database, the Plans must make any 4Rx edits directly with the Transaction Facilitator using the form below:

Note: Proxy Add, Edit and Deletes may only be used for non-Plan of Records. If information needs to change for a plan of record, it must be corrected via an eligibility file change with CMS or with the processor, whichever is incorrect.

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