(Medicare Claims Processing Manual)

 Social Security Administration's (SSA) reply to Form  CMS -1980 in the case of entitlement questions; and    A copy of the Health Insurance Master Record Entitlement Status Query (ESQ) received from an SSA District Office.   The criteria are:   Two follow -ups have been made to the Social Security Office (SSO) and the CWF Master Record has not been corrected;   At least 60 days have elapsed since the correction procedures were initiated;   A serious hardship to the beneficiary or a public relations problem has developed;   Corrections or changes to HMO termination dat es are necessary; and   The SSO response indicates that both the MBR and HI Master Records are correct.   The MAC marks the information "CRITICAL CASE." The MAC flags the file for special handling and expedites the claim as soon as the reply is received.   The MAC must diary the case for 30 calendar days.  By that time the RO should have a response and advise the MAC. If the MAC receives a positive basic reply record before hearing from the RO, it notifies the RO.   50 - Requesting or Providing Assistance to Res olve CWF Rejects  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  When a MAC has difficulty processing a bill because a prior bill was incorrectly processed and posted to CWF by another MAC (A/B MAC or DME MAC), the two  A/B MACs or DME MACs must work together to resolve the error. Where help is needed from another A/B MAC or DME MAC, the submitting MAC requests assistance from the contractor whose bill was processed incorrectly.  The A/B MAC or DME MAC that processed the bill i s identified in the CWF reject trailer.   50.1 - Requesting A/B MAC or DME MAC Action  (Rev. 3468, Issued: 02- 18-16, Effective: 12 -02-15, Implementation: 12- 02-15)  The requesting A/B MAC or DME MAC  furnishes the assisting A/B MAC or DME MAC  with sufficient information to identify the issue and perform the necessary resolution actions.  The data shown on the Request for Assistance Form (see Exhibit 1) is needed.  This format must be used when designing a form letter so that both the requesting A/B MAC or DME MAC 's address and the assisting A/B MAC or DME MAC 's address will be visible through a window envelope.  A separate page is used for each request to enable the assisting A/ B MAC or DME MAC  to return each claim as completed instead of holding claims until all claims on a request are completed.  The requesting A/B MAC or DME MAC  enters its request after "The following action is requested."  The requesting A/B MAC or DME MAC  provides claim -identifying information as shown.  The requesting A/B MAC or DME MAC  adds information to help it associate the response with its pending record, if needed.   If a response has not been received within 30 calendar days of the request, the requesting A/ B MAC or DME MAC  sends a follow -up request.  If no response is received within an additional 15 days, follow -up with the RO responsible for the assisting A/B MAC or DME MAC .  A status report indicating and defining problems that prevent processing of the request is considered a response in deciding whether to follow -up with the RO.  In addition, the requesting A/B MAC or DME MAC  considers whether an interim payment  to the provider without CWF approval is appropriate.  (See 60 of this chapter for procedures for paying without CWF approval.)   50.2 - Assisting A/B MAC or DME MAC Action  (Rev. 3468, Issue d: 02 -18-16, Effective: 12 -02-15, Implementation: 12- 02-15)  Upon receipt of a request for assistance, the assisting A/B MAC or DME MAC  adjusts or cancels the posted bill, as appropriate, and informs the requesting A/B MAC or DME MAC  by annotating the request form (under explanation of action taken by assisting A/B MAC or DME MAC ) with a description of its action (e.g., adjustment cleared CWF (date), current dates of service are __________.)  The assisting A/B MAC or DME MAC  completes corrective actions wit hin 30 calendar days of receiving the request.  If it cannot complete action within 30 days, provide a status reply explaining the reasons on a copy of the request form.  The assisting A/B MAC or DME MAC  sends a copy of the reply to the RO.  The assisting A/B MAC or DME MAC  uses the request form on all correspondence to the requesting A/B MAC or DME MAC  to facilitate association of its response with the pending action.  50.3 - Format for Requesting Assistance From  Another A/B MAC or DME MAC on CWF Edits (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18)  Exhibit 1 contains the required format for requesting assistance.  The requesting A/B MAC or DME MAC uses that format in designing its form letter so that both its address and the assisting A/B MAC or DME MAC's  address will be visible through a window envelope.  The requesting A/B MAC or DME MAC  completes all data elements. Note that the form is designed so that a standard number 10 - 4 1/8 by 9 1/2 inch window envelope can be used for your request.  The assisting A/B MAC or DME MAC  may refold the form and use the same size window envelope in its reply.  The requesting A/B MAC or DME MAC  enters its address in the bottom address space, and uses the following in the top address space:   A/B Medicare Administrative Contractor or DME MAC (as applicable) or   Name of Contractor PO Box or Street Address City, State, ZIP Code  Exhibit 1 - Request for Assistance     Date ___________      To:  Request:  ___ First     ___ Follow up     ___ RO copy        Date of First Request  _______________     (If Follow up)      We request assistance in resolving CWF reject, edit code _______________________    enter code #   The following action is requested:   IDENTIFYING INFORMATION    ______________________________  ___________________________________  Medicare beneficiary identifier  Beneficiary Name    ______________________________  ______________________________  Your ICN  Your Provider    ______________________________  ______________________________  From Date  Through Date    Explanation of action taken by assisting A/B MAC or DME MAC:     REQUESTOR INFORMATION     __________________________________   Claim #     __________________________________   Dates of Service    Response Date  __________________________________  ____ Final  Provider  ____ Status  __________________________________   Other  Return To:   Requesting Contractor Name   Address Line 1  __________________________________  Address Line 2  Contact Person and Phone #  Address Line 3 (if needed)    60 - Paying Claims Outside of CWF (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  The CWF approves each claim before it is paid.  However, there may be special circumstances when it is necessary to pay claims outside the CWF/CWF system.  The CMS will notify the A/B MAC or DME MAC of these instances.  They include, but may not be limited to:    New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes to CWF timely; and,    Errors are discovered in CWF that cannot be cor rected timely.  All  A/B MACs and DME MACs  are responsible for reporting CWF problems to their host sites.  60.1 - Requesting to Pay Claims Outside of CWF  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  A/B MACs or DME MACs  may  also request approval from CMS in specific situations to pay claims without CWF approval.  Examples of such situations are:    Other A/B MACs or DME MACs  cannot complete action to remove an impediment that blocks a contractor from processing of a claim; and/or    A systems error cannot be corrected timely, and the provider's cash flow will be seriously endangered.    Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside th e normal CWF process.   A/B MACs or DME MACs  shall obtain approval from CMS to pay a claim without CWF approval prior to processing that claim outside the CWF/CWF system.  A/B MACs and DME MACs  shall submit a written request to their CMS Contracting Officer Representative (COR)  for approval to make payment without CWF approval.  Such requests shall be submitted by facsimile transmission or via the Internet.  To ensure the protection of the Personal Health Information (PHI) and Personally Identifiable Information (PII) contained in contractor requests  to pay claims without CWF approval, contractors shall encrypt their E -mail submitted requests.   A/B MACs or DME MACs  shall provide the following information to their CMS COR when requesting to pay a claim without CWF approval:   a) A/B MAC or DME MACs  Internal Claim Control Number,  b) Medicare beneficiary identifier,  c) Beneficiary Name,  d) Provider Number (National Provider Identification (NPI) Number),  e) From and To Date of Service,  f) Procedure Code(s),  g) Total Charges,  h) Amount to be Paid, i) CWF Er ror Code/Condition Preventing Payment (including error code definition), and j) Rationale for Paying the Claim Outside the CWF/CWF System.   60.2 - Procedures for Paying Claims Outside of CWF  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04 -23-18)  Before a claim can be paid outside the CWF/CWF system, A/B MACs or DME MACs  shall obtain approval from their CMS COR, or  his/her designee.  In all instances involving payment outside the CWF/CWF system, A/B MACs or DME MACs  shall  apply the following procedures , unless otherwise specified:    Submit the claims with an "X" in the tape -to-tape flag, and the system will determine payment as if the payment were final.  Inpatient PPS payments shall be processed through MCE, Grouper and Pricer.  Hospice payments shall be made using the appropriate hos pice rate.  ESRD visits shall be paid using the composite rate.  The appropriate fee schedules or interim rates shall be used.  Deductible and coinsurance shall be applied based on the most current data available.  Do not apply the CMS -prescribed  percent r eduction applicable to accelerated payment.    Follow shared system procedures to avoid sending a claim to the CWF at time of payment, but shall also maintain a record for later submission.    Pay interest accrued through the date payment is made on clean clai ms.  Do not pay any additional interest.   Maintain a record of payment and implement controls to be sure that duplicate payment is not made (i.e., when the claim record is updated to CWF or in response to a duplicate request by the provider).    Monitor the CWF to determine when the impediment to CWF processing is removed.  Additionally, A/B MACs and DME MACs  shall update the CWF when the impediment is removed so that the actual payment date outside the CWF is shown in the scheduled payment data field.    Consider the claim processed for workload and expenditure reports when it is paid.   60.3  Contractor Monthly Reports of Claims Paid Outside of CWF   (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  A/B MACs and DME MACs shall submi t, by the 20th day of the following month, a monthly report of all claims paid without CWF approval to their CMS COR.  A/B MACs and DME MACs shall encrypt reports submitted via the Internet to ensure the protection of the Personal Health Information (PHI) and Personally Identifiable Information (PII) contained in these reports.  The monthly reports of claims paid outside the CWF/ CWF system shall include summary data for each edit code showing claim volume and payment.  The reports shall also identify the c laims and summary edit code volume and payment data as to whether it is a Part A or Part B Service.  The monthly reports shall provide the data listed below for each claim paid without CWF approval for that reporting month: