(Medicare Claims Processing Manual)

20.3 - Records received from the CWF Hosts  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  20.3.1  BDS Basic Reply  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) When the Host receives a query from MACs requesting beneficiary eligibility and entitlement information, the informational record is sent in response to the BDS Transaction record sent to the host. It acknowledges the Host's receipt of the BDS Transaction  record and indicates any errors or informational data.   Following are the types of codes and other information associated with this record: These codes are returned on Basic Reply Trailer 08 and other reply trailers as appropriate   Disposition codes;   Error codes;  and  Basic Reply Trailers.  20.3.2 - Claims Basic Reply  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) When the Host receives each claim or adjustment, it searches the Beneficiary File to find the Beneficiary Record.  I f the Beneficiary Record is found, the record is processed and a reply record is transmitted to the MAC.  See 20.3.3, for an explanation of t he procedure if the Beneficiary Record is not found ("Not in File.")  The record type returned by CWF is dictated by the claim record type as follows:   A/B MAC (B)  Basic Reply Record -  Reply record for each CWF A/B MAC (B) bill (HUBC) processed.   DMEPOS Basic Reply Record -  Reply record for each CWF DMEPOS bill (HUDC) processed.   Inpatient/SNF Bill Basic Reply Record -  Reply record for each Inpatient/SNF bill (HUIP) processed.   Outpatient/Home Health Bill Basic Reply Record -  Reply record for each Outpatient/Home Health bill (HUOP and HUHH) processed   NOE/Hospice Bill Basic Reply Record -  Reply record for each Hospice Notice of Election and all subsequent Hospice bills (HUHC) processed.   Each reply record will contain a disposition code and error code  that indicates the action taken on the bill by the Host and what action the MAC should take next. The following is a list of actions that CWF may take on a claim record. Disposition codes, cross -reference/alpha search/NIF situations, their associated trai lers, and bill recycling instructions are also included:  20.3.2.1 - Accepted (as is) for Payment  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The claim record is posted to CWF history as submitted to the Host.  The MAC pays the claim accordingly.   Disposition code 01.  Basic Reply Trailers -  These are informational trailers that contain entitlement, utilization, MSP, or other information, as appropriate, and are returned with the Reply.  They give the MAC the most recent inform ation available about the beneficiary's claim history and other important data.  MACs must use this information to update their own data to improve the accuracy of future claims processing.   Return Alerts -  These are sent to the MAC when CWF believes that there is a potential problem or error in the claim.  The presence of an alert indicates that the MAC should examine the information and make adjustments if necessary.  20.3.2.2 - Adjusted and Then Accepted f or Payment  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The deductible and/or payment limitations field(s) on the claim record were in error and CWF recalculated the field(s).  The Host posts the record to CWF after these co rrections are made.  The MAC must make the same adjustments to its files using information from basic reply Trailers 07 and 11 and pay the claim accordingly.  MACs must not resubmit the claim to CWF.   Disposition code 02  Basic Reply Trailers (07 and 11)   A/B Crossover Alerts  20.3.2.3 - Cancel/Void Claim Accepted                                                               (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) This action cancels or voids a previously processed claim post ed to CWF History.  All utilization and deductibles associated with the claim are backed out.  The MAC receives a disposition code informing it that the cancel/void action was accepted.   Disposition code 03  Basic Reply Trailers  20.3.2.4 - Rejected  (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) The claim record contains errors that prevent CWF from posting the claim to history.  The claim is returned to the MAC with codes explaining the errors.  The MAC must correct the CWF Claim Record and resubmit it.   Disposition Code ER, UR, CR, or AA, as Appropriate -  There will never be a combination of ER, UR, CR, and AA error codes on the same reply.  Consistency Error Codes (ER) - Consistency edits examine the information on the claim itself.  The consistency error codes indicate the errors in consistency found on the claim.  These codes are returned on Basic Reply Trailer 08 and can contain up to four consistency error codes.  Utilization Error Codes (UR) - Utilization edits compare the  information on the CWF Claim Record with the information found on the CWF Beneficiary Master Record.  The utilization error codes indicate discrepancies between the CWF Claim Record and the CWF Beneficiary Master Record.  Since the CWF Beneficiary Master Record is presumed to be correct, these codes inform the MAC what corrections it must make.  The code is returned on basic reply Trailer 08 and contains only one utilization error code. FPS:  If FPS denies the claim record, CWF will stop processing the clai m and return a response back to the MAC with FPS error code.  Disposition Code UR  The utilization error code indicate the errors found on the claim. These codes are returned on Basic Reply Trailer 08, 48 and 49 indicating partial denial (FPSD) or full denial of the claim (FPSH).   A/B Crossover Edits (CR) - When the Host receives a Part A bill, CWF automatically checks the information in the record against the beneficiary's history files for both Part A and Part B utilization.  If there is a conflict (or "crossover") of services, CWF will generate an A/B Crossover error code.  These are returned on the reply Trailer 13 and will contain only one A/B crossover error code.  20.3.3 - Not in Host's File (NIF)  (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) When the Host receives a claim record from a MAC, it first searches its beneficiary and cross reference files.  If it does not find the beneficiary's record in either place, it searches the Transfer Not in File (TNIF) file.  If the record is not found there, the Host puts a response on the reply record in the form of a disposition code 50 or 52, indicating that the Beneficiary Record for which the MAC submitted a claim record is not located at the MAC's Host.  The TNIF fil e contains a record of every beneficiary for whom the Host has received a claim, and whose records are located at another Host.  It shows at which Host the beneficiary file resides.  If the Beneficiary Record is located at another Host, the original Host c hecks the out -of-service area response file to see if the claim record response is already waiting there.  If there is not a response waiting, the claim is sent to the proper Host for processing.  If there is a response, the Host gives that information to the MAC.  There are many disposition codes that are returned to the MAC for various NIF situations.  Following is a list of codes and actions the MAC takes in response to each disposition code. 20.3.3.1 - Disposition Code 50 (Not in File)  (Rev. 4009, Issued : 03-23-18, Effective: 04 -23-18, Implementation: 04- 23-18) Disposition code 50 can come with any of the following seven error codes:  1. With Error Code 5052 -  Beneficiary Identification Incorrect -  The name and/or claim number shown on the bill is incorrec t or claim number is not in file.  If the TNIF file does not indicate another Host, the beneficiary's records may not have been assigned to a Host and are still resident at CMS or the beneficiary was  assigned to another Host site and the TNIF File was not updated.  When the Host is not sure which is the case, it gives disposition code 50 and Trailer 08 with error code 5052 on the reply to the MAC.  A/B MACs and DME MACs  verify through inquiry to the Host that the HICN is correct on the bill.  If the bill is  correct, and the Host HIMR agrees with the reject (no record), A/B MACs and DME MACs  must notify the Host of the error.  The Host will contact CMS to determine eligibility.  2. With Error Code 5054 -  The Host returns code 50 with Trailer 08 and error code 5054 when an auxiliary indicator is present on the CWF Beneficiary Master Record, but no auxiliary record is found.  Concurrent with this response to the MAC, the Host sends a request for transfer to CMS requesting the beneficiary's records from CMS' Master  File.    The A/B MAC or DME MAC  must recycle the claim every four working days until an approval, adjustment or reject (AAR) response is received, or 45 working days have passed since receipt of the original code 50.   The A/B MAC or DME MAC  reports through locally established procedures to the Host if 45 days pass with no AR response.  3. With Error Code 5055 -  The Host returns code 50 with Trailer 08 and error code 5055 (Beneficiary Blocked at CWF Host and CMS Batch Pending Clerical Update) if CMS must investigate a beneficiary's entitlement because of suspicion of fraud or abuse.  The MAC recycles the claim every 15 working days until otherwise notified. Definition of Day One for CWF MAC Recycle  - Day one is the day that the MAC receives the disposition code back from the Host.  For example, a MAC sends the update file to the Host on Monday, April 1, at 10 p.m.  The MAC receives the response file from its Host site at 9 a.m. Tuesday, April 2.  Tuesday, April 2, is day one for MAC recycle.  4. With Error Code 5056 -  The Host returns code 50 with Trailer 08 and error code 5056 (Skeleton -  No Beneficiary Record on HI Master File) when the HICN involved is for a beneficiary whose date of death is prior to 1975.  The records for these beneficiaries h ave been purged from the file.   A/B MACs and DME MACs  research the HICN and confirm that the HICN submitted on the claim is correct.  If incorrect, it resubmits the claim with the correct HICN.   If the originally submitted HICN was correct, A/B MACs and DME MACs  refer the case to the RO.   5. With Error Code 5057 -  The Host returns disposition code 50 with Trailer 08 and error code 5057 (Skeleton on HI Master File).  This indicates that the beneficiary has died.  There has been no claims activity for six months  since date of death, and the beneficiary information is located on the inactive file.  A/B MACs and DME MACs  research the HICN and confirm that the HICN submitted on the claim is correct.  If incorrect, resubmit the claim with the correct HICN.   If the orig inally submitted HICN was correct, the A/B MAC or DME MAC  recycles the claim every 15 working days to allow CMS time to retrieve the records.