(Medicare Claims Processing Manual)

Data on claims that the A/B MAC or DME MAC receives from its keyshop or image processing systems may not be included on the SFR, depending on the shared system design. The A/B MAC and DME MAC will create the Medicare claim/COB flat file using data available fr om claims history and reference files. Since some data will not be available on these paper claims, the outbound COB transaction will be built as a minimum dataset.  It will contain all required COB transactions segments and post-adjudicative Medicar e data.    The steps from receipt of the incoming claim to creation of the outbound COB are summarized below:    A/B MACs and DME MACs translators perform syntax edits and map incoming claim data to the ASC X12 flat file;   Standard system creates any Medicare edits for the flat file data;    Medicare data on ASC X12 flat file is mapped to the core system;   NOTE: There are no changes in core system data fields or field sizes.   Non-Medicare data (and Medicare data elements where field sizes are in excess of the core system) are written to the SFR; and adjudicated data are combined with repository  data to create the outbound COB.  Under the COBA process, the BCRC  will receive flat  files containing processed Medicare claims.  The BCRC  will then convert the flat files into the appropriate HIPAA outbound COB format and transmit the claims to the COBA trading partner.   80.1 - Reserved  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  80.2 - Reserved  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  80.3 - Medigap Electronic Claims Transfer Agreements  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  80.3.1 - A/B MAC (A)/A/B MAC (HH) Crossover Claim Requirements (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  A.  Outbound COB   The outbound COB transaction is a post -adjudicative transaction.  This transaction includes the incoming claim data as well as COB data.  A/B MACs (A) are required to receive all possible data on the incoming ASC X12 837 although they do not have to proces s non- Medicare data.  However, the shared system must store that data in a SFR.  This repository file will be designed and maintained by the shared system.  This data must be re -associated with Medicare claim and payment data in order to create an IG compl iant outbound COB transaction using the Medicare Part A Claim/COB flat file as input.  The shared system is to use post -adjudicated Medicare data (data used from history and reference files to adjudicate the claim) instead of data received when building the outbound COB transaction.  The shared system must retain the data in the SFR for a minimum of six months.   The Medicare Part A Claim/COB flat file is the format to be used to re -associate all data required to map to the COB transaction.  The translator w ill build the outbound COB transaction from the Medicare Part A Claim/COB flat file.   The shared system maintainer must accommodate the COB transaction.   A/B MACs (A) shall refer to 70.6 through 70.6.5 for additional guidance concerning the national COBA crossover process.   B.   Summary of Process   The following summarizes all A/B MAC (A) steps from receipt of the incoming claim to creation of the outbound COB:    A/B MAC (A)s translator/edit process performs syntax edits, IG edits, and Medicare edits and m aps incoming claim data to the Medicare Part A Claim/COB flat file;  Medicare data on the Medicare Part A Claim/COB flat file is mapped to the core system by the shared system.    NOTE : No changes are being made to core system data fields or field sizes;   Non-Medicare data (and Medicare data elements where field sizes are in excess of the core system) are written to the SFR by the A/B MAC (A)s shared system; and  Adjudicated data is combined with SFR data to create the outbound COB transaction.   80.3.2 - A/B MAC (B)/DME MAC Crossover Claim Requirements (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  A. Outbound Coordination of Benefits (COB)   The outbound COB transaction is a post -adjudicative transaction.  This transa ction includes incoming claim data as well as COB data. A/B MACs (B)/DME MACs are required to receive all possible data on the incoming ASC X12 837 although they do not have to process non- Medicare data.  However, they must store that data in a store- and-forward repository (SFR).  This repository will be designed by the shared system.  This data must be re- associated with Medicare claim and payment data in order to create an outbound ASC X12 837 COB transaction.  The shared systems maintainer is to use post -adjudicated Medicare data (data used from history and reference files to adjudicate the claim) instead of data received when building the outbound COB transaction.  A/B MACs (B)/DME MACs must retain the data in the SFR for a minimum of six months.   The AS C X12 -based flat file is the format to be used to re -associate all data required to map to the outbound ASC X12 837. The translator will build the outbound ASC X12 837 COB from the ASC X12 -based flat file.   The shared system maintainer must create the outb ound ASC X12 837.  B. Summary of Process  The following summarizes all the steps from receipt of the incoming claim to creation of the outbound COB:    A/B MAC (B)/DME MACs translator performs syntax edits and maps incoming claim data to the ASC X12 flat file;     Standard system creates implementation guide and Medicare edits for the flat file data;    Medicare data on ASC X12 flat file is mapped to the core system;   NOTE: No changes are being made to core system data fields or field sizes.   Non-Medicare data (and Medicare data elements where field sizes are in excess of the core system) are written to the store- and-forward repository; and   Adjudicated data is combined with repository data to create the outbound COB.   90 - Reserved  (Rev. 2906, Issued: 03 -14-14, Effective: 04-14-14, Implementation 04-14-14)   100 - Medigap Insurers Fraud Referral  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)   All MACs should give high priority to fraud complaints made by Medicare supplemental insurers. If the referral by a Medigap insurer includes investigatory findings indicating fraud stemming from site reviews, beneficiary interviews, provider interviews and /or medical record reviews, all MACs should (a) conduct an imm ediate data run to determine possible Medicare losses and (b) refer the case to the Office of the Inspector General (OIG).   In addition to the referral of such cases to the OIG, all MACs should also identify and take additional corrective action to prevent future improper payments (e.g., by placing the provider or suppliers claims on prepayment review).  All MACs are responsible for taking reasonable and appropriate measures to protect the Trust Fund.  110 - Medigap Criminal Penalties/Types of Complaints Under Section 1882(d)  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)   Although most States have some type of penalty provisions regarding fraud and misrepresentation in the sale of health insurance policies, Congress considered that many State laws either did not directly address the following types of abuses, or else the sanctions generally available under State laws were considered too limited. Therefore, in order to provide an additional avenue for prosecution of these cases as well as to provide stiff penalties (fines up to $25,000 and/or imprisonment for up to five years) these provisions were included in Section 507 of P.L. 96-265.  A.  Section 1882(d)(l) - This paragraph prohibits the making of a false representation with regard to the compliance of a policy with the Federal requirements contained in this law.  Additionally, it prohibits the making of any false statement or misrepresentatio n  with respect to the use of the emblem that signifies the Secretarys certification of a policy under the Voluntary Certification Program. Policies submitted under this Voluntary Certification Program were accepted for review by the Medigap Operations Staff beginning January l, 1982. Any agent or company which represents that its policy has received the Secretarys certification, or that its policy has received or is eligible for the Secretarys emblem, when, in fact, it has not received such certification  or emblem, can be prosecuted under this paragraph. This paragraph became effective June 9, 1980.  B.  Section 1882(d)(2) - This paragraph prohibits the false representation of an association or agency relationship with the Medicare program or any Federal agency for the purpose of selling insurance. Of the complaints received by CMS, the majority involves alleged violations of this paragraph. These complaints indicate that agents gained entry and, in some cases, sold policies by misrepresenting, either by direct statement or by implication, that they were associated with Medicare, CMS, or the Social Security Administration.  This paragraph became effective June 9, 1980.  C.  Section 1882(d)(3) - This paragraph provides penalties for knowingly selling duplicative coverage (sometimes referred to as stacking or loading).  This occurs when  an agent sells insurance to an individual knowing that it duplicates coverage that he/she already has without duplicating benefits. This paragraph became effective June 9, 1980.  Although many States have statutes that specifically prohibit twisting (misrepresentations made by an agent for the purpose of inducing the policyholder to lapse, forfeit, or convert a policy), few States have specific prohibitions against stacking.  Therefore, Federal prosecution under 1882(d)(3) may prove to be a useful approach where the available State statute does not specifically prohibit stacking.  Moreover, the Federal sanctions available for misrepresentations and stacking may prove to be useful for prosecution where the available State sanctions are more limited.  D.  Section 1882(d)(4) - This paragraph provides penalties for knowingly soliciting, advertising, or offering for sale Medicare supplemental health insurance policies by mail into a State if these policies have not been approved by the Commissioner of Insurance for sale within the State or are not deemed to be approved for sale within the State.  Section 1882(d)(4)(B) sets out the situations for deeming that a policy is approved within a State.   110.1 - Outline of Complaint Referral Process  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)  Representatives of CMS, the Office of the Inspector General (OIG) and the Department of Justice (DOJ) have consulted to develop a coordinated procedure for the screening, investigation, and prosecution of cases arising under these penalty provisions.  The Fraud Section, DOJ, has expressed great interest in the prosecution of these cases and has sent an official communiqu to all U.S. Attorneys addressing the existence and  importance of the Medigap law and alerting them to the probability of referrals of cases developed jointly by CMS, OIG, and by State Insurance Departments.  A.  CMS/OIG Agreement   The CMS and OIG have reached the following agreement as to the division of functional responsibilities with regard to the screening and investigation of alleged violations of 1882(d):   1. CMS, through its regional offices, is responsible for the preliminary screening of complaints and for providing information regarding the complaints to the appropriate State Insurance Department.   2. The OIG is responsible for the investigation of cases referred by the CMS RO and for coordinating investigatory activities with the State Ins urance Departments if requested and warranted. Further, OIG will provide any necessary liaison between State Insurance Departments and the U.S. Attorneys.  B.   CMS RO Responsibilities   Upon receipt of a complaint, the RO sends an informational copy of the  complaint and any supporting documentation to the Regional Office of the Inspector General. The Special Agents in Charge will serve as the OIG contact point for CMS referrals.   Additionally, the RO sends a copy of the original complaint and any supporting documentation to the appropriate State Insurance Department. This is to be accompanied by a request for information as to the status of any State investigation regarding the same agent or company or the specific case in question.