(Medicare Claims Processing Manual)

20.2 - Recor ds received by the CWF Hosts (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) 20.2.1 - Beneficiary Data Streamlining (BDS)                                           (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04 -23-18) The BDS system provides access to a common eligibility service which occurs earlier in the claims lifecycle than the CWF eligibility check. The BDS transactions, 'HBDA' for Part A, 'HBDB' for Part B, and 'HBDD' for DME, will allow the Shared Systems claims processing to query eligibility edits for Part A, Part B, and DME claims. The BDS system uses the CWF data repository to provide eligibility and entitlement responses to the Shared Systems query. The information is returned on a BDS Basic Reply Record.  ( See 20.3.1)  BDS records can be of the following types:  A/B MAC (A)  Claim Record:   A/B MAC (A)  bills are input on the HBDA record.   A/B MAC (B)  Claim Record:  A/B MAC (B)  bills are input on the HBDB record.  DMEPOS Claim Record:  DMEPOS bills are input on the HBDD record.    20.2.2  Claims                                                                                             (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) The CWF Claim Record is a record of a claim that the MAC has processed and is ready for payment or denial.  It is submitted in daily files to the Host for approval.  Prior to the approval CWF Host will send the claim to Frau d Prevention System (FPS) for review.  Role of FPS :  FPS interacts directly with the CWF Hosts and performs these functions:  Receive files submitted by CWF Hosts with claims approved for payment.  Process claims using proven predictive modeling tools to ide ntify high risk claims.   Make a payment determination that is returned to the CWF Hosts for appropriate action.  Only denied claims will be included in the returned file.   The Host clears the claim record through regular CWF consistency edits, utilization edits and A/B crossover edits, in that order, and makes its approval, adjustment or rejection determination.  The final determination is returned on a Claim Basic Reply Record.  (See 20.3.2)  Claim records can be of the following types:   Part B  Claim Record: Part B bills are input on the HUBC record.   DMEPOS Claim Record:  DMEPOS bills are input on the HUDC record.   Inpatient/Skilled Nursing Facility Claim Record:  Inpatient hospital and SNF bills are input on the HUIP record.   Outpatient Claim Record:  Outpatient bills are input on the HUOP record.   Home Health Claim Record:  Home health bills are input on the HUHH record   Hospice Claim Record:  Hospice bills are input on the HUHC record.   20.2.3 - Adjustments/Cancels to Posted Claims  (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) Two actions can be taken on a claim that is already posted to CWF history.  These actions are the same whether submitted by an A/B MAC or DME MAC ; however, the codes used are different:   Void - Use a void to cancel original data on the beneficiary database and totally remove the dollar amounts.  To void a posted claim, send the claim with the original document control number and a "Full Credit" code (Entry Code 3 for A/B MACs (B) and DME MACs and Action Code 4 for A/B MACs (A, HHH)) ).  Change - Send a full claim with a "Replacement Debit" code (Entry Code 5 for A/B MACs (B) and DME MACs  and Action Code 3 for A/B MAC s (A, HHH) ) and the original document control number to make a change to a posted claim.  This code is used to change most claims information.  The old claim information will be backed out and replaced with the new claim information.  The CWF will keep a record of the old claim so that any investigation of the actions taken on the claim will include the fact that there was a replacement action taken.  20.2.4 - Claim Maintenance Records                                                         (Rev. 4009, Issued : 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) The CWF Claim Maintenance Record is a record of a transaction that the Medicare Administrative Contractors are submitted in daily files to the CWF Host to update the related auxiliary file information that is used for claims processing approval.  The final determination is returned on a Basic Reply Record.  (See 20.2.2.)  Claim Maintenance records can be of the following types:  Medicare Secondary Payer (MSP): Medicare Secondary Payer information (Primary insurer data when Medicare is secondary) is input on the HUSP record.  End Stage Renal Disease (ESRD):  Beneficiary ESRD data input on the HURD record.   Certified Medical Necessity (CMN): Beneficiary Certified medical necessity data is input on the HUCM record.  Beneficiary Other Insurance Information (BOI): Beneficiary Other insurance information data is inp ut on the HUBO record.   Beneficiary Libby Montana (Libby): Beneficiary Libby information data is input on the HUEP record.  Beneficiary Prior Authorization (PRAU): Prior Authorization data is input on the HUPA record.   Intravenous Immune Global (IVIG): Benefi ciary Intravenous Immune Globulin information data is input on the HUIV record.    20.3 - Records received from the CWF Hosts  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)