New CMS Guidelines for Individuals Not Lawfully Present—Are Your Systems Ready?

Ensuring Member enrollment records are accurate is no easy task. The Centers for Medicare and Medicaid Services (CMS) makes policy changes regularly, and it is up to the individual Health Plans to keep up.

Last November, CMS announced in an HPMS memo they would make updates to their policy for Individuals Not Lawfully Present. Effective June 26, 2022, individuals who are not lawfully present in the United States will be disenrolled. From the memo:

CMS will provide to Plans information about not lawfully present status via MARx and MBD (a subsystem of the enrollment and eligibility system, ELMO). We are making systems changes for lawfully present status to the Batch Eligibility Query (BEQ) process, and Daily Transaction Reply Report (DTRR). Through these means, CMS will convey the start date and end date, if applicable, of a not lawfully present status period.

If an individual is ineligible for Medicare enrollment, the Plan must deny the enrollment request.

A Plan should not submit enrollment transactions for individuals reflected in CMS systems as ineligible due to not lawfully present status. If a Plan inadvertently submits an enrollment transaction to CMS for a current unlawfully present individual, CMS will reject the enrollment and notify the Plan with a Transaction Reply Code (TRC) on the DTRR.

SyncRecon™ is Here to Help

SyncRecon can help ensure your plan is ready for new CMS Guidelines for Individuals Not Lawfully PresentSyncRecon™—CODY’s Synchronicity™ Reconciliation Solution helps Plans manage daily membership operations seamlessly while maintaining accurate enrollment information. Crafted from decades of experience in healthcare operations, CODY’s SyncRecon™ Solution provides full-service tools to streamline operations and deliver actionable transactions.

Our Daily Transaction Reply Report (DTRR) directly supports Plans adhering to CMS policy and procedural changes—just like the one referenced above. The SyncRecon™ TRR module includes:

  • Customized TRC processing—Plans define which TRCs are actionable vs. automated
  • Actionable TRCs are workflow-driven for accurate processing
  • Letters triggered directly from TRCs processed
  • TRR sub-queues allow multiple departments to manage work independently
  • Streamlines operations, improves performance, and timeliness standards

Complementary to our TRR module, the SyncRecon™ Out of Area (OOA) Module manages multiple sources of possible OOA statuses, including notifications from call centers, claims, providers, returned mail, and in-area State & County Code (SCC) notifications. It tracks to account for different timeframes due to plan type and temporary absences.

SyncRecon™ is compliance-driven and built specifically to support Medicare Advantage plans in reducing administrative costs. SyncRecon™ modules are easy to implement & quick to learn. There’s no need for onsite implementation, no special coding skills required, and no hardware or software to install. Synchronicity™ is housed in a secure HIPAA/HITECH audited facility where all data is encrypted and stored in a client-dedicated data mart.

For a full-service solution, bundle our Business Process as a Service (BPaaS) offering with SyncRecon™ TRR and OOA Modules for a highly efficient, cost-effective, end-to-end outsourcing solution. Or subscribe directly to manage your work items in our user-friendly web portal.

Find out how CODY® can help streamline your TRR & OOA processes, mitigate compliance risk, and contain costs. Contact us today to learn more or request a demo.


About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Synchronicity™, our proprietary suites of software, are designed specifically for health plans. www.codyconsulting.com