CMS Guidelines for Supplemental Benefit Reporting

In the evolving landscape of healthcare data reporting, the Centers for Medicare & Medicaid Services (CMS) acts as the body that releases new guidelines and regulations to be followed by healthcare providers and organizations to enhance transparency and improve patient outcomes. In February 2024, CMS introduced an updated guidance specifically aimed at Medicare Advantage (MA) Organizations. This guidance focuses on the submission of encounter data records related to supplemental benefit services.

Wondering what this new medical buzz is all about? In this blog, you’ll dive into the CMS guidance on supplemental benefit reporting and discover its key advantages. You’ll also discover the services included under the supplemental benefits umbrella as you read.

So, let’s get started!

What is a Supplemental Benefit?

Any service or item can be considered a supplemental benefit if the following three conditions are met:

Fig: Supplement Benefit Conditions

These benefits are offered exclusively through Medicare Advantage plans. They are neither provided by Medicare Providers nor at Medicare Certified practice or facility.

These help to enhance the patient’s experience, offering more flexibility and targeted support for health conditions or preventive care. This contributes to better management of individual health outcomes.

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Onwards toward the plethora of supplementary benefits!

Supplemental Benefits – Umbrella of Services
All the services must be delivered by a state-licensed practitioner, operating within the state where they are licensed and adhering to that state’s licensure and practice guidelines.

Here is a list of services that qualify as supplemental benefits:

Why is CMS focusing on supplemental benefit data submission?

Supplemental benefits have increased significantly over the last five years, and CMS has paid MA groups more than twice as much per individual for these services. They have invested in new programs to gather more data on the usage and value of supplemental benefits.

Note: Organizations providing supplemental benefits to their enrollees must report encounter data starting with the 2024 contract year, CMS intends to:

• Monitor these submissions
• Provide technical support as needed
• Seek feedback on any challenges
• Offer additional guidance

I’d now request you to be aware of the roadblocks while submitting EDRs (Encounter Data Records) for supplemental benefits. Knowing these will help you avoid delays, ensure accurate reporting, and streamline the submission process.

Challenges while submitting EDRs for Supplemental Benefits

Here are the 2 probable challenges that you might have to face:

1. MA organizations may lack information like National Provider Identifiers (NPIs), procedure codes, diagnosis codes, and/or revenue codes needed in the relevant EDR (Endpoint Detection and Response) fields for submitting supplemental benefits.
2. Benefits are either not provided in a manner that allows for normal reporting practices without additional guidance from CMS, or the data required to complete an X12 837 Version 5010 record will be missing.

Let’s move on to learn about the guidelines for submitting supplemental benefit data!

Guidelines for Submitting Supplemental Benefit Data to CMS

Here is the list for organizations to follow when submitting supplemental benefit data to CMS:

A. The CMS collects Medicare Advantage encounter data (ED) using the X12 837 Version 5010 format, which is the standard for electronic health care claims.

Note: Supplemental benefit data is to be submitted in the Encounter Data Record (EDR) format.

B. The specific segment in the EDR format used to indicate supplemental benefits is Paperwork (PWK) segment.
These segments are used as a supplemental benefit indicator on encounter data submissions (837 format).

Note: The supplemental benefits are submitted on EDRs and not via CRRs.

C. The four data items in the 2400 Loop (line level) that make up the Supplemental Benefits Indicator shall look like following:

D. CMS has established default values for diagnosis codes, procedure codes, revenue codes, NPIs, and Employer Identification Numbers (EIN) to use when these data elements donot exist for a given item or service.

Note: The default procedure code is SBSP1.

E. Here are details about the dates of service, quantity, and units present in the EDRs:

• The Professional/Institutional Loop 2400 contains the dates of service information.
• The relevant unit count is reported in the quantity fields of Loop 2400 for both professional and institutional claims.
• The frequency of EDR submissions should correspond to the periodicity of the benefit.

For example, if a fitness benefit is provided quarterly, submit it with a quantity of 1 and report one EDR for each active quarter.

F. These are the guidelines for reporting supplemental benefits provided as allowances:

• The total allowance should be populated on the line-item charge amount.
• The amount utilized by the beneficiary should be entered in the Service Line Paid Amount.
• The Line-Item Charge Amount must not be left blank.
• Use Loop 2430 for both professional and institutional claims.

G. This is the process for reporting combined supplemental benefits:The MA organization must separate utilization by service category. For each category, a separate EDR should be submitted when reporting supplemental benefits that are part of a combined benefits package, as outlined in their Plan Benefit Package (PBP).

For example, if a plan covers 15 total supplemental vision and hearing visits and the MA organization is reporting the utilization of a single supplemental routine vision visit, then the PWK06 field should be populated with 17a1zz.

H. Utilization of supplemental benefits can be reported based on the following:

• Every time an enrolled person truly utilizes the benefit, a record of utilization needs to be filed.
• When reporting each instance of benefit use is impractical, such as with a physical fitness membership, MA organizations should report either when a participant first received and used the benefit, or the portion of the benefit used by the end of the benefit period.

For example, if a monthly gym membership starts in January and ends in March, submit an EDR for each month: January, February, and March.

I. Please keep a note of these scenarios:

• For countable service units, record every instance of usage along with the corresponding date of service.
• Each usage of an allowance or payment card must be reported together with the items or services that were purchased with it. When per-utilization reporting is impractical, submitters may report the amount of an allotment consumed depending on card periodicity.

Note: CMS has recently issued a guidance for submission of dental benefits in August 2024. I’d recommend referring to it if required.

Despite the challenges mentioned above, it is essential to address and overcome them to ensure accurate and compliant reporting. Therefore, by understanding the requirements and seeking guidance when needed, organizations can streamline the submission process.

At Nitor Infotech, we are committed to helping you navigate these complexities and achieve successful reporting outcomes. So, don’t hesitate to contact us at Nitor Infotech.

Also, write to us about your queries about health tech and let us know of any guidelines that haven’t been mentioned here.