(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 27 - Contractor Instructions for CWF   Table of Contents  (Rev. 11427, 05-20-22)  Transmittals for Chapter 27   10 - General Information About the Common Working File (CWF) System  20 - Common Working File (CWF) Operations  20.1 - Communication between Host and MACs Jurisdiction Sector  20.2 - Records received by the CWF Hosts  20.2.1  Beneficiary Data Streamlining (BDS)  20.2.2 - Claims  20.2.3  Adjustments/Cancels to Posted Claims  20.2.4 - Claim Maintenance Records  20.3 - Records received from the CWF Hosts  20.3.1- BDS Basic Reply  20.3.2- Claims Basic Reply  20.3.2.1 - Accepted (as is) for Payment  20.3.2.2 - Adjusted and Then Accepted for Payment  20.3.2.3 - Cancel/Void Claim Accepted  20.3.2.4 - Rejected  20.3.3 - Not in Host's File (NIF)  20.3.3.1 - Disposition Code 50 (Not in File)  20.3.3.2 - Disposition Code 51 (True Not in File on CMS Batch System)  20.3.3.3 - Disposition Code 52 (Beneficiary Record at Another Host)  20.3.3.4 - Disposition Code 53 (Record in CMS Alpha Match)  20.3.3.5 - Dis position Code 54 (Matched to Cross- referenced HICN)  20.3.3.6 - Disposition Code 55 (Personal Characteristic Mismatch)  20.3.3.7 - Disposition Code 56 (MBI/HICN Mismatch)  20.3.4 - Claim Maintenance Record s Basic Reply  20.3.5 -  Unsolicited Response/Informational U nsolicited Response (UR/IUR)  30 - Reviewing the Beneficiary and Claim(s) Information  30.1-  Online Health Insurance Master Record (HIMR) Display  30.2-  CWF Provider Queries -  Online Eligibility Information for Medicare Part A  Providers  30.3-  Online Reporting (ORPT) System Display    40 - Requesting Assistance in Resolving CWF Utilization  40.1-  Requesting Assistance in Resolving CWF Utilization P roblems  40.2-  Social Security Administration (SSA) Involvement  40.3 -  Critical Case Procedure -  Establishing Entitlement 40.4 -  Referral of Critical Cases to the Regional Office  50 - Requesting or Providing Assistance to Resolve CWF Rejects  50.1 -  Requesting A/B MAC or DME MAC Action  50.2 -  Assisting A/B MAC or DME MAC Action  50.3 -  Format for Requesti ng Assistance From Another A/B MAC or DME MAC on CWF Edit s Exhibit 1 -  Request for Assistance 60 - Paying Claims Outside of CWF  60.1 -  Requesting to Pay Claims Outside of   CWF  60.2-  Procedures for Paying Claims  Outside of   CWF  60.3 -  Contractor Monthly Reports of Claims Paid Outside of  CWF  70 - Change Control Procedures  70.1-  MAC  Procedure  70.2 -  Process Flow of a Cha nge Request  70.3 -  Handling Emergency Problems and Problems With Recent CWF Releases  70.4 -  Distribution of "CWF Change Control" Reports  70.5 -  Channels of Communication 70.6 -  Schedule of CWF Software Releases  80 - Processing Disposition and Error Codes  80.1 -  Disposition Codes  80.2 -  Error Code s 80.3 -  Beneficiary Other Insurance Information (HUBO) Maintenance Transaction Error Codes  80.4 -  Consolidated Claims Crossover Process  80.5 -  Claims Crossover Disposition and Coordination of Benefits Agreement Bypass  Indicators  80.6 -   Special Mass Adjustment and Othe r Adjustment Crossover Requirements  80.7 -  Coordination of Benefits Agreement (COBA) Medigap Claim -Based Crossover Process  80.8 -  Inclusion and Exclusion of Specified Categories of Adjustment Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes  80.9 -  Health Insurance Portability and Accountability Act (HIPAA) 5010 and National Council for Prescription Drug Programs (NCPDP) D.0 Cr ossover Requirements  80.10 -  Inclusion and Exclusion of Specified Part B Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes    10 - General Information About the Common Working File (CWF) System  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  The Common Working File (CWF) is the Medicare Part A and Part B beneficiary benefits coordination and pre -payment claims validation system which uses localized databases maintained by designated contractors called CWF Hosts.  The CWF System software is duplicated and utilized by the nine CWF Hosts localized databases  to process claims.  Each Medicare beneficiary is assigned to only one Host site based on beneficiary geographic location.  CWF Hosts maintain total beneficiary claim history and entitlement information for the beneficiaries in their jurisdiction.   Each ju risdiction is a network of A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs),  termed Satellites,  and located in a defined geographic area (sector).  Each MAC within the sector is l inked to its Host via telecommunications through their respective CMS Virtual Data Center (VDC).   The Medicare Part A, B or DME processing system creates a nightly CWF file out of the MACs processing region, containing claims data. The corresponding MACs  VDC transmits these files to the CWF Host.  The CWF Host uses the CWF software and determines the beneficiary's eligibility and entitlement status and uses that information to decide what action should be taken on the claim.  The CWF software also checks incoming claims against all other claims types, referred to as A/B crossover, previously processed and stored in claims history to prevent duplicate payments.  The Host returns a response file back to the VDC and the file is loaded to the MACs processing r egion. The file will contain various disposition codes, trailers, and error codes, used by the processing systems in automatic processing during the batch cycle.  The responses are applied to the pending claim allowing appropriate system action. 20 - Commo n Working File (CWF) Operations                                         (Rev. 11427; Issued: 05- 20-22; Effective: 01 -01-23; Implementation: 01- 03-23)  NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthet ics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the inform ation found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after  January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.  This section is intended only to be a brief profile synopsis of CWF operations. The system and user documentation should be closely examined for further details.   The Common Working File system provides a single data source where the contractors can verify beneficiary eligibility to receive prepayment review and approval of claims.  Each Host site is responsible for processing those claims submitted for beneficiaries on its database.  These claims are processed through a shared  software system supplied to each Host by the CWF Maintenance Contractor (CWFM). Each change made to the CWF software is released to all Host sites in a uniform manner.  This software performs consistency and utilization editing on claims for corrective action by the MACs.  The CWF system ensures that:  1. The beneficiary is entitled to either Part A or Part B benefits, depending on the type of claim submitted.  2. The co -pay and/or deductible applied, if any, is accurate. 3. Services are allowed.  4. Benefits are available for the services submitted on the claim  The CWF system also ensures that the services on the claim have not been paid on another claim - either the same type or another type of claim. If any of these conditions occur, the CWF system returns a response and identifies the reason for the rejection. The response also includes one or more trailers that identify the correct information necessary for the Medicare contractor to take the necessary action.   Prior to adjudication of claims, the CWF Host will sen d the claim to Fraud Prevention System (FPS) for review. FPS will make a payment determination which will be sent to the CWF Host. The CWF Host will then process the claims through consistency and utilization to ensure beneficiary is entitled to either Par t A or Part B benefits, depending on the type of claim submitted.   Once the claim passes all of the edits, the CWF beneficiary master file is updated to reflect the benefits now available, as well as any changes to the deductible status. The claim is added to the CWF full claim history file.   CWF also provides eligibility and entitlement check via the beneficiary data streamlining (BDS) system which occurs earlier in the claims lifecycle to check for Medicare beneficiary identifier, eligibility and entitlement prior to the submission of the claim.   20.1 - Communication between Host and MACs Jurisdiction Sector    (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) The local CWF database for each sector resides at a Host.  Each A/B and DME MAC within the sector is linked to its Host's database.  Communication between them is electronic, with claims ready for payment or denial communicated to the Host, and adjustments, approvals, rejects, and informational trailers returned from the Host via a daily process.  The A/B and DME MACs usually initiates this process.  On occasion, the CWF Host will initiate an "unsolicited response" to the A/B and DME MACs as a result of a new claims action that affects a previously processed claim act ion. Claims are processed by CWF in the same order that they are received, regardless of the dates of service or receipt date.  This first -in-first-out method of processing requests for payment facilitates prompt handling of claims.  Role of CWF Hosts:   Responsible for executing a common set of CWF software modules to maintain Beneficiary databases by adding or updating Beneficiary entitlement information provided by CMS  o These updates are processed by the enrollment database (EDB) and continue to update CWF Host records as the beneficiary's entitlement changes.   Perform consistency; utilization, A/B cross over and duplicate edit checks to provide authorization for MACs to pay claims;   Providing and controlling linkage of the MACs in the sector to the Hos t; Controlling and monitoring telecommunications network operations  Supplying MACs with inquiry and transmission software necessary to communicate with the Host and make full use of the CWF data inquiry features;   Receiving, installing, testing, and operating the CWF software system, including all changes developed by CWFM;   Role of A/B and DME Medicare Administrative Contractors (MACs):   Submission of claims via telecommunication in batch mode to a CWF Host for validation and payment approval;   Receive, control, and enter claims into an automated processing system.   Review, edit, and adjudicate claims through CWF system for determination of eligibility, coverage, and pricing.   Submission of online inquiries to a CWF Host to determine Beneficiary enrollment status and eligibility   Submit claims to the CWF Host for pre -payment validation and authorization.  Issue payments to Providers or deny/develop claim is rejected by CWF; - Issue Explanation of Medicare Benefits and payments to Beneficiaries.