CMS Query Issue
Heather Sanderson
June 2, 2015

In November 2014, pursuant to the SMART Act, CMS implemented a process where RREs could use a partial SSN (last 5 digits) where the RRE was unable to obtain the full SSN when reporting ORM and TPOCs.

A recent issue has been identified where RREs have been using only a partial SSN during the Section 111 query process. Franco Signor has been made aware that when  RREs query a claim with only a partial SSN, CMS may incorrectly return false positive Medicare Beneficiary hits.  The false positive is accompanied by a notice to update the date of birth (DOB) with a DOB that is different from what was submitted to CMS.

The problem stems from how a CMS Query matching process works.  CMS asks for 5 pieces of data; SSN, First Name (first initial only), Last Name (first 6 characters only), Gender, and DOB.  The required match is the SSN.  In addition to this requirement, three (3) of the other four (4) fields must match.  Prior to the partial SSN implementation, a full SSN was unique enough not to cause false positives.  With the acceptance of partial SSN, the “SSN and 3 out of 4 matching process” can produce false positives.   There are numerous SSN that end in the same last 5 digits.  All that is then needed is a match of the First Initial First Name, First Characters Last Name, and Gender.

Take for example the name Robert Johnson.  During the matching process CMS would look for “R. Johnso”.  Add to this, that only a partial SSN is used (last 5 digits) it is conceivable that a number of people with the first initial “R” and the last name starting with “Johnso” could have the same last five digits as being submitted for query.  This creates a problem, because if a RRE updates the date of birth it may unknowingly being implicating a Medicare beneficiary that is NOT the claimant.

CMS has been alerted to this issue.  Until a fix can be created, we are urging all our clients to continue to use complete SSNs when submitting queries.  On the chance that complete SSNs are not supplied by our clients, we are monitoring our CMS matching results for attempts to update date of birth information or other information that does not match the claim record in our file.

We will continue to provide updates as they arise.

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
Chief Legal Officer
Franco Signor LLC