(Medicare Claims Processing Manual)

20.3.3.7 - Disposition Code 56 (MBI/HICN Mismatch)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) Specific to new Medicare Beneficiary Identifier (MBI) processing, disposition code 56 can come with any of the following three error codes:  1. With Error Code 5060 -  MBI entered is not found on the CWF file.  2. With Error Code 5061 -  HICN entered is not found on the CWF file.  3. With Error Code 5062 -  HICN and Submitted MBI combination on the claim do not belong to the same beneficiary.  A/B MACs shall ret urn the provider claims as unprocessable. When returning these claims as unprocessable, the shared processing system shall use Claim Adjustment Group Code (Group Code) CO  Contractual Obligation, Claim Adjustment Reason Code (CARC) 16 -  Claim/service lack s information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Rem ittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present, and RARC N382: Missing/incomplete/invalid Medicare beneficiary identifier.  20.3.4  Claim Maintenance Records Basic Reply   (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) This informational record is sent in response to the Claim Maintenance Transaction Record sent to the host it acknowledges the Host's receipt  of the Claim Maintenance Transaction Record and indicates any errors or informational data. If accepted, the claims maintenance record is posted to CWF auxiliary database as submitted to the Host. Following are the types of codes and other information ass ociated with this record. These codes are returned on Basic Reply Trailer 08.    Disposition codes; SP, RD, CM, BO, EP, PA or IV , as appropriate   Transaction Error codes; The error codes indicate the errors in consistency found on the transaction   Basic Reply . Trailer 08 containing up to four error codes  20.3.5 - Unsolicited Response/Informational Unsolicited Response (UR/IUR)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) CWF system also returns unsolicited response/informational unsolicited response to MACs when the processing of a current claim results in the need for action on a previously paid claim. Generally, changes in a beneficiarys entitlement or utilization history information on Beneficiary trigge r UR/IUR response. The information used to process the earlier claim is no longer accurate and the claim must be corrected.  CWF typically sends these responses to MACs in an immediate reaction to claims the contractor has recently submitted. An unsolicited response is an instruction from CWF to act on a previously paid claim days or even months after the paid claim received its original CWF response.   Unsolicited response (UR) : CWF cancels or adjusts a claim in CWF history and sends the information in basic  reply trailers (08 and 24) to the MACs to take action.   Informational unsolicited response (IUR) : CWF system takes no action on a claim in history, but sends basic reply trailers (08 and 24) to MACs to perform corrective action.  30 - Reviewing the Benefi ciary and Claim(s) Information                         (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) 30.1 - Online Health Insurance Master Record (HIMR) Display  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation : 04-23-18) Beneficiary entitlement and utilization data on all nine CWF databases is available online through the HIMR transaction.  It allows the MAC to do further investigation about a claim or inquire about beneficiary entitlement and utilization status.  This fun ction is a display of information only.  The user at the MAC site cannot make changes to the screens accessed through HIMR.   This information is applicable only to MACs and Host site staff.  30.2 - CWF Provider Queries - Online Eligibility Information for Medicare Part A Providers  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  The CWF will provide access to the Part A Eligibility System. MAC and/or Medicare Part A Providers can request the beneficiary master information from  the CWF host via HIQA/ELGA and HIQH/ELGH inquiry screens to obtain the information. The information can also be requested though unformatted query, HUQA. These functions are for display of information only.  The user at the MAC and/or Provider site cannot  make changes to the screens accessed through eligibility system.   30.3  Online Reporting (ORPT) System Display  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  The CWF will provide access to online reporting system (ORPT) to MACs. The ORPT Reporting System will locate data for a designated Contractor and display it on the screen. CWF identifies the location of MACs reporting data at remote Hosts based on information available in the local Host's Contractor table re cords. This function is a display of information only.  The user at the MAC site cannot make changes to the screens accessed through ORPT system.   40 - Requesting Assistance in Resolving CWF Utilization  (Rev. 1, 10- 01-03) B3-6008  40.1 - Requesting Assistance in Resolving CWF Utilization Problems  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  This section applies only to MACs; it does not apply to providers.   In the normal course of claims processing activities, MACs can expec t to encounter problems involving the CWF Claim Record and/or basic reply record procedures.  The action necessary to resolve the problem depends upon the problem identified.  For utilization problems and/or HICR requests, the MAC enters the issue into the  secure online inquiry system, Host Request Inquiry (HURQ), provided by the CWF Host, and sends all master beneficiary, summary history, and inpatient summary history screen-prints for the beneficiary to the CWF HICR contractor for investigation.  The MAC takes the following steps:    Put the error code causing the problem in the upper right -hand corner of the Beneficiary Master screen print;    Mark on all of the screen prints exactly what the problem is and what is believed to be the correction needed;    The MAC (contractor) sends these marked screen prints to the CWF HICR contractor.  They coordinate with the other contractor to determine who needs to correct the problem; and    The CWF HICR contractor will investigate the problem and correct it.  If a response is not received within 45 days of mailing the request for assistance, the contractor sends a second request marked "SECOND REQUEST."   NOTE :  Congressional requests are faxed to the CWF HICR contractor. Faxes must be reviewed and corrective action taken within 24- 48 hours of receipt.   For problems involving the Host CWF Site, the MAC utilizes the HICR transaction.  This transaction provides t he Host CWF site a method of creating transactions that correct the local database.   40.2 - Social Security Administration (SSA) Involvement  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  SSA maintains the Master Beneficiary Record (MBR) from which the Health Insurance (HI) Master Record is established.  The CWF's eligibility record is accreted from this HI Master Record.  The HI Master Record is updated periodically from a variety of sources, including the MBR, and in turn updates the Host maintaining the CWF record.  However, errors occur where the MBR fails to correctly update the HI Master Record or where the HI Master Record fails to correctly update the CWF record.   If the problem is caused by difficulties in determining the beneficiary's correct entitlement status, the A/B MAC or DME MAC must request assistance of the SSO. The SSO is responsible for processing the case.  Examples of situations covered by this procedure are:    Problems involving Railroad Retirement Board (R RB) jurisdiction, i.e., the RRB has jurisdiction of the beneficiary's Medicare, and the claim was erroneously referred to the area A/B MAC (B);    Evidence that a beneficiary has utilization under more than one health insurance claim number (HICN), but the M AC is not aware of any cross -reference action taken by CMS; or    Assistance is needed to obtain or verify a beneficiary's name and/or MBI.  (See specific procedures in 20.3.3.6 under disposition code 55.)   In the event the SSO is unable to res olve the entitlement problem, e.g., a disposition code 55 is received after SSA verified the beneficiary's name and/or MBI, the MAC requests assistance from the RO. It includes complete details of the nature of the problem and a description of its efforts to resolve it.  40.3 - Critical Case Procedure - Establishing Entitlement  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  The MAC uses the "critical case" procedure (see 40.4, below) to expedite the processing of claims which have been delayed because of an error in the beneficiary's CWF Master Record.  The "critical case" procedure provides speedy correction of the master record.  The MAC uses this procedure when there is an error in the CWF Master Record, which prevents the receipt of an approval disposition code on the basic reply record.  This may occur when one of the following conditions exists:    The MAC is unable to make payment on a claim even though the beneficiary apparently has entitlement because CWF transmitted a Basic Reply Record with an inaccurate or repeated disposition code of "50," "51," 52," "53," "54," "55," "57," "58," "59," "60," "61," "AB," "CI," "ER," "UR," "CR;" or    The MAC received a Basic Reply Record and the recycled CWF Claim Records have not received a disposition code, which permits processing the claim to payment or denial.   40.4 - Referral of Critical Cases to the Regional O ffice (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  When the MAC identifies a claim meeting the criteria listed below, it contacts the RO via established referral methods.  The MAC identifies the beneficiary by name and MBI,  specifies the nature of the problem, states that the criteria are met, and gives the dates of all actions.  The MAC provides all available supporting documentation.  Examples of such documentation are:    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)