• Samir Upadhyay

Impact of PAID Act

CMS has released the most awaited NGHP User guide for the PAID Act (Provide Accurate Information Directly Act) Implementation today. For this release, let us look into the series of information to follow on the updates by chapter.

Chapter 2

Effective as of December 11, 2020: In 2020, the Provide Accurate Information Directly Act (PAID Act) was passed to help NonGroup Health Plan (NGHP) Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates, on the Query Response File (Chapter 3).

On December 11, 2021, the PAID Act will be fully implemented by the CMS. This means that the CMS will be expanding the current information in its Query Response File to include data on claimants to determine if they are currently or during the preceding years entitled to Medicare Part C (Medicare Advantage) and/or Part D (Prescription Drug) benefits. This will be a substantial change in the layout of Query Response File.

Chapter 3

Additional guidance has been provided regarding termination of ongoing responsibilities for medical (ORM). An ORM termination date should only be submitted if one of the following criteria has been met:

  1. No claims were paid with any diagnosis codes related to alleged ingestion, implantation, or exposure.

  2. No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim.

  3. Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device.

  4. The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Details on (Section 6.3.2)

Chapter 4

Updates to Technical Information Chapter Version 6.4

The Event Table, which helps RREs and their agents determine when, and how, to send records on the Claim Input File, has been updated to cover situations where ongoing responsibility for medicals (ORM) ends for one injury due to Total Payment Obligation to Claimant (TPOC), but then continues for another injury (Section 6.6.4).

The CMS electronic file transfer (EFT) file-naming conventions for inbound and outbound files have been updated (Section 10.2).

Updates to PAID Act

To support this act, the Query Response File will be updated to include: Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage. The updates will also include the most recent Part A and Part B entitlement dates.

More information on the additional data can be found on the NGHP User Guide here. Changes to the record layout can be found in Chapter V Appendix E-6 Query Response File Record of the User Guide.

The HIPAA Eligibility Wrapper Software (HEW) software will also be modified to extract the additional fields from the response file.

Steps for installing and configuring the HEW software are listed in Chapter V, HEW Query Response File Record – Version 4.0.0, Appendix K “HEW Installation and Configuration”.

If you’re worried that your current CMS tool isn’t ready to handle the change brought about by the PAID Act, then we have a solution for you! Spiralogics has developed a specialized tool that will help you convert the new query response file and make it compatible with the old format to keep your CMS tool running.

To know more, contact us directly at or (770) 209-9596.


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