(Medicare Claims Processing Manual)

 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:   a) Medicare beneficiary identifier,  b) Beneficiary Name,  c) Provider Number (National Provider Identification Number (NPI),  d) From and to Date of Service,  e) Total Charges,  f) Amount Paid, g) Paid Date, and  h) CWF Error Code/Condition Preventing Payment.  70 - Change Control Procedures (Rev. 4088, Issued: 07- 13-18, Effective: 08 -14-18, Implementation: 08- 14- 18)   The CWF software is changed quarterly to accommodate revised CMS requirements, new provisions of law, to correct errors, or to enhance the system.  A/B MACs and DME MACs may also request changes to CWF through certain change control procedures.   70.1 - MAC Procedure  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  When a MAC has a recommendation for software changes, it follows the change control process below:    Enter change requests into the CWF Information Management System (INFOMAN).     After entering change requests into INFOMAN, submit all supporting documentation to the Host for review and forwarding to both CMS and the CWF Maintenance Contractor (CWFM) for consideration and entry into the Change Control System.    Monitor progress of all changes submitted from your site through INFOMAN.   Review implementation of all changes from your own site to insure that needs a re addressed.   70.2 - Process Flow of a Change Request  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)   Complete a CWF Change Request (CR) through INFOMAN. When the CR is created a CR number will automatically be assigned.    Forward three copies of all supporting documentation to the Host site. Include the CR number on all documentation.  The Host will review it and the CR for accuracy, completeness, and relevance.  The review may also determine whether a problem reported is a CW F problem or a problem with the MAC's software.    When the Host approves the CR, it releases the Change Request to the CWFM and to the CMS central office (CO) in accordance with current procedures.    CMS and the CWFM review the Change Requests as received th roughout the month.   CMS distributes all change requests to the appropriate CMS component for review and approval as they are received.    A monthly Change Control meeting of CMS and CWFM staff is held to schedule approved Change Requests for release.    Following the meeting, the CWFM enters approval and priority status of all Change Requests into the automated system.  As work progresses, the CWFM enters the status of all changes, Quality Assurance (QA) activities and work performed.   70.3 - Handling Eme rgency Problems and Problems With Recent CWF Releases  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  A problem is considered an emergency if a large number of claims are paid incorrectly, cannot be paid, or the MAC/Host system abnormally ends (abends).  When an emergency occurs, the MAC follows these procedures:   1. The MAC will convey information about the emergency to the Host immediately.  The MAC must be able to submit documentation of the problem.   2. The Host wil l report the problem to the CWFM immediately via CWFM customer service.  The service is available 24 hours a day, 7 days a week.   3. During business hours, CWFM will respond immediately.  After business hours, CWFM will contact the Host within one hour of report of the problem.   70.4 - Distribution of "CWF Change Control" Reports Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)   CWFM distributes a monthly "Status of CWF Changes" report and "Schedule of CWF Changes" report to all Host  sites, CMS ROs, and CMS CO staff.    Each Host site distributes the reports to its MAC sites within three working days of receipt.   70.5 - Channels of Communication  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  All MAC inquiries should be made to the Host staff, according to locally established procedures.   70.6 - Schedule of CWF Software Releases  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)   Regular Releases  - Scheduled quarterly releases  normally contain changes due to both routine maintenance and new CMS mandates. Other changes included in a regular release shall be in response to issues submitted through the CWF Change Control Process or Sustainability CRs requested by CMS .   Emergency Releases  - Emergency off -quarter releases shall be in response to a critical problem prioritized as a P1 or P2, which causes a delay in processing, or causes claims not to be paid or paid incorrectly. An effective date for an emergency release shall be det ermined in advance by the CMS CWF team.   Generally, an emergency release shall be distributed by the CWFM via telecommunications facilities and installed immediately by the CWF Hosts with the formal approval of CMS. The CWFM shall open a problem into the INFOMAN system for error tracking purposes when the emergency is confirmed. Technical assistance shall include analyzing requirements and debugging programs, data, or file structures that result in operational problems or that interferes with normal operat ional processing. The CWFM shall review, analyze, develop, and document each problem. The CWFM shall group problems according to functionality for the purpose of updating, correcting, modifying, and enhancing the CWF system software .   Special Releases  - Special off -quarterly releases shall be provided as needed in response to situations which are of a particular or unusual date dependent nature. These releases shall be provided, for example, in response to a special project approved by CMS that may be of a high priority nature. The CWFM shall not move special releases to production without the permission of CMS. N o less than 24 hours prior to the release moving to production, the CWFM shall send an email to the CMS CWF team requesting approval for implementing the special release. The email shall list all CRs and problem fixes scheduled for implementation.    Priority Releases  - Priority off -quarter releases are scheduled in response to resolve as a follow -up to incomplete or inaccurate changes that are made due to any previous software release. They generally arise from problems in the system that was not evident prior to a relea se being implemented. Priority releases are generally scheduled bi -weekly, except during the final month of each quarter, where minimal changes are permitted. A production release date for a priority release shall be determined in advance by CMS CWF team, the CWFM and implemented with the formal approval of CMS. No less than 24 hours prior to the release moving to production the CWFM shall send an email to the CMS CWF team requesting approval for implementing the priority release. The email shall list all C Rs and problem fixes scheduled for implementation.  80 - Processing Disposition and Error Codes  (Rev. 4088, Issued: 07- 13-18, Effective: 08 -14-18, Implementation: 08- 14- 18)   The results of CWF processing are communicated through a set of codes categorized as either disposition or error codes.  There are specific disposition codes for inquiry, transfer/not in file request, and each claim type.  Claims have consistency, utilizat ion, A/B crossover, and duplicate error codes.   Transactions for End Stage Renal Disease (ESRD), Medicare Secondary Payer (MSP), and Certificate of Medical Necessity (CMN) error codes, as still applicable, are also available.  If the Host rejects a claim, the A/B MAC or DME MAC shall either adjudicate the claim systematically or suspend the claim and review it.  After the review is complete and corrections made, the A/B MAC or DME MAC resubmits the claim with an indication that a review was performed and co rrections made.   80.1 - Disposition Codes (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) Each reply record will contain a disposition code that indicates the action taken on the bill by the Host and what action the MACs shoul d take next.   Below are the list of common disposition codes applicable to CWF processing 01  -Approved  03  -Cancel Accepted  04  -Accrete History (Action Code 07 or Entry Code 09) Accepted  50  -Not in file  51  -Not in file on CMS batch system  52  -Master Record housed at another CWF site  53  -Record in CMS alpha match  54  -Matched to Cross -referenced HICN  55  -Does not match master record  56  -MBI/HICN mismatch  60  -I/O Error on database  61  -Cross reference/database problem  AA -Auto Adjust error  AB -Transaction caused CICS ABEND  BO -Beneficiary Other Information (HUBO) edits  CI  -CICS processing problem  CM -Certified Medical Necessity (HUCM) Edits  CR A/B Crossover Reject  ER  -Consistency Edit Reject  EP -Libby Montana (HUEP) project edits  IV -Intravenous Immune Globulin transaction (HUIV) edits  PA -Prior Authorization transaction (HUPA) edits  RD - End Stage Renal (HURD) transaction edits  SP  -Medicare Secondary Payer transaction (HUSP) edits  UR - Utilization Reject  80.2 - Error Codes                                                                                       (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The results of CWF error processing is controlled by different set of components. There are specific  error codes for each claim type and maintenance transactions. Claims have a Consistency, Utilization, A/B Crossover, and Duplicate error codes.    Transactions for Medicare Secondary Payer (MSP), End Stage Renal Disease (ESRD), Certificate of Medical Necessity (CMN), Beneficiary other insurance (BOI), Libby Montana (HUEP), Prior Authorization (HUPA),and IVIG error codes are also available.  Below are the list of high level error functions performed during the CWF processing  1. Inpatient, SNF, Outpatient, Home  Health, and Hospice consistency edits,  2. Part B/DMEPOS consistency edits,  3. Entitlement edits,  4. Duplicate edits,  5. Inpatient, SNF, Outpatient, Home Health, and Hospice utilization edits,  6. Part B/DMEPOS utilization edits,  7. A/B Crossover edits, 8. Medicare Secondary Payer (MSP) consistency/utilization edits, 9. MSP transaction (HUSP) edits,  10. Certified Medical Necessity (CMN) consistency/utilization edits,  11. CMN transaction (HUCM) edits,  12. End Stage Renal Decease (HURD) consistency/utilization edits,  13. ESRD transactio n (HURD) edits,  14. Beneficiary Other Information (BOI)/Claim based crossover edits,  15. BOI transaction (HUBO) edits,  16. Libby Montana (HUEP) project edits,  17. Prior Authorization (PRAU) consistency/utilization edits,  18. PRAU transaction (HUPA) edits,  19. Immune Globulin (I VIG) consistency/utilization edits,  20. IVIG transaction (HUIV) edits, and 21. BDS/FPS and other processing edits.