evekhm/cms_iom_500 huggingface dataset:
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 The A/B MAC or DME MAC  must recycle the claim every four working days until an approval, adjustment or reject (AAR) response is received, or 45 working days have passed since receipt of the original code 50.   The A/B MAC or DME MAC  reports through locally established procedures to the Host if 45 days pass with no AR response.  3. With Error Code 5055 -  The Host returns code 50 with Trailer 08 and error code 5055 (Beneficiary Blocked at CWF Host and CMS Batch Pending Clerical Update) if CMS must investigate a beneficiary's entitlement because of suspicion of fraud or abuse.  The MAC recycles the claim every 15 working days until otherwise notified. Definition of Day One for CWF MAC Recycle  - Day one is the day that the MAC receives the disposition code back from the Host.  For example, a MAC sends the update file to the Host on Monday, April 1, at 10 p.m.  The MAC receives the response file from its Host site at 9 a.m. Tuesday, April 2.  Tuesday, April 2, is day one for MAC recycle.  4. With Error Code 5056 -  The Host returns code 50 with Trailer 08 and error code 5056 (Skeleton -  No Beneficiary Record on HI Master File) when the HICN involved is for a beneficiary whose date of death is prior to 1975.  The records for these beneficiaries h ave been purged from the file.   A/B MACs and DME MACs  research the HICN and confirm that the HICN submitted on the claim is correct.  If incorrect, it resubmits the claim with the correct HICN.   If the originally submitted HICN was correct, A/B MACs and DME MACs  refer the case to the RO.
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5. With Error Code 5057 -  The Host returns disposition code 50 with Trailer 08 and error code 5057 (Skeleton on HI Master File).  This indicates that the beneficiary has died.  There has been no claims activity for six months  since date of death, and the beneficiary information is located on the inactive file.  A/B MACs and DME MACs  research the HICN and confirm that the HICN submitted on the claim is correct.  If incorrect, resubmit the claim with the correct HICN.   If the orig inally submitted HICN was correct, the A/B MAC or DME MAC  recycles the claim every 15 working days to allow CMS time to retrieve the records.
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 After 45 working days have passed with no approval, adjustment, or reject (AAR) response, MACs contact their RO. 6. With Error Code 5058 -  The Host returns disposition code 50 with Trailer 08 and error code 5058 (Blocked).  The records have been blocked due to cross -reference activity.  There are two numbers for one beneficiary, both of which show claims activity.  The information is manually placed under one primary number in one record.  MACs recycle the claim every 15 working days to allow time for CMS processing.   After receiving a second code 58, they contact the RO. 7. With Error Code 5059 -  The Host returns this as disposition code 50 and Trailer 08 with error code 5059 (Frozen).  Miscellaneous clerical corrections are being made to these beneficiary records.   MACs recycle the claim every 15 working days.   After receiving a second code 59, the A/B MACs or DME MACs  contact the RO. 20.3.3.2 - Disposition Code 51 (True Not in File on CMS BatchSystem)   (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The Host gives this response with a 08 Trailer and error code 5052.  The CMS has performed an alpha search of its records and cannot locate the beneficiary's records.  Alpha search is the process of searching for the records based on the first six positions of the surname.  All beneficiaries with the same first six letters in their sur names are listed with their HICNs.  The system checks for possible matches, including the possibility that numbers were transposed.  This search is performed only if no match is found during the search by HICN.  This code can be given in two forms:  1.  With  Trailer 01  - Trailer 01 will contain a possible corrected HICN.  The A/B MAC or DME MAC  investigates the possible HICN and, if it believes the new HICN is for the same beneficiary, it resubmits the claim with the new HICN to the Host.  The CWF will respond with the appropriate disposition code and any associated trailers for processing the claim.  2.  Without Trailer 01 -  This response indicates that after performing the alpha search operation, no match is found against the HICN submitted and
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the Host.  The CWF will respond with the appropriate disposition code and any associated trailers for processing the claim.  2.  Without Trailer 01 -  This response indicates that after performing the alpha search operation, no match is found against the HICN submitted and CMS records.  Since Medicare eligibility cannot be established, A/B MACs and DME MACs  shall return the claim to the provider as unprocessable and take the following actions:   A/B MACs (A, HHH ) shall return to provider (RTP) Part A claims.  A/B MACs (A, HHH)  shall not mail an MSN for these claims.   A/B MACs (B) and DME MACs  shall return as unprocessable Part B claims.  A/B MACs (B) and DME MACs  shall use Group Code CO and Claim Adjustment Reason (CARC) 140 (Patient/Insured health identification number and name do not match).  A/B MACs (B) and DME MACs  shall not mail an MSN for these claims.   For assigned and unassigned Part B claims submi tted by the beneficiary on the Form CMS -1490S or Form CMS -1500, A/B MACs (B) and DME MACs  shall manually return the claim in accordance with Pub.100- 04, chapter 1, section 80.3.2 A. "Special Considerations."  20.3.3.3 - Disposition Code 52 (Beneficiary Reco rd at another Host)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  When CMS receives a request for transfer, it searches its Master File to determine if the Beneficiary Record resides at another Host.   The CMS first searches th e record based on the HICN.  If a match is found, and the beneficiary has not already been assigned to a Host, CMS sends the records to the requesting Host. After the Host receives the record, it can process the claim from the MAC on its next cycle.   If a m atch is found that indicates the beneficiary has been assigned to another Host, CMS sends the requesting Host a code 52. The requesting Host then sends the claim information to the receiving Host that has the
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next cycle.   If a m atch is found that indicates the beneficiary has been assigned to another Host, CMS sends the requesting Host a code 52. The requesting Host then sends the claim information to the receiving Host that has the Beneficiary Record.   The requesting Host will gi ve the processing MAC a code 52 and Trailer 08 with a 5052 error code.   The MAC holds the claim and resends (recycles) it in five working days to see if there is a response waiting.   If the response is present on the first recycle of the claim, the MAC finis hes processing the claim according to the response.   If a response is not present, the MAC receives another disposition code 52 and the claim is sent to the proper Host for processing.   The MAC recycles the claim after another five working days, and continue s recycling the claim until it receives an approval, adjustment, or reject (AAR) response, or until 45 working days have passed.   After 45 working days have passed with no AAR response, the MAC reports the problem to the Host through locally established reporting procedures.  20.3.3.4 - Disposition Code 53 (Record in CMS Alpha Match)                  (Rev. 4047, Issued: 05- 11- 18, Effective: 08 -13-18, Implementation: 08- 13-18)  If CMS sends a claim to alpha search, it must send a disposition code 53 to the Host.  The Host puts a code 53 on its TNIF file.   The Satellite receives code 53 and Trailer 08 with a 5052 error code on the next recycle of the claim.   The Satellite must recycle the claim 15 working days after receiving this code.   If an AAR response is not received after the receipt of the third code 53 for the same claim, the Satellite must deny the claim using the following messages: MSN message 5.1:  "Our records show that you do not have Medicare entitlement under the number shown on this  notice. If you do not agree, please contact your local Social Security office."  Group Code CO, Claim Adjustment Reason Code (CARC) 16 (Claim/service lacks 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
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(Claim/service lacks 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 Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identific ation Segment (loop 2110 Service Payment Information REF), if present), and Remittance Advice Remark Code (RARC) N382 -  Missing/incomplete/invalid patient identifier . 20.3.3.5 - Disposition Code 54 (Matched to Cross -referenced HICN)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The Host provides the MAC with disposition code 54 and Trailer 08 with error code 5052 when it discovers a cross -reference number in its own files for the name or number the MAC submitted. Disposition C ode 54 applies only to A/B MAC (B) or DME MAC - submitted claims.  The possible number and the new full name is returned to the MAC on Trailers 1 and 10.   The A/B MAC or DME MAC investigates the information provided and corrects the information on the claim and resends it.   If the MAC continues to receive a code 54, it contacts the Host through locally established procedures.  20.3.3.6 - Disposition Code 55 (Personal Characteristic Mismatch)         (Rev.  4047, Issued: 05- 11-18, Effective: 08 -13-18, Implementati on: 08- 13-18) The Host provides the Satellite with this disposition code and Trailer 08 with error code 5052 when it discovers a mismatch of the Health Insurance Claim Number (HICN) with the beneficiarys personal characteristics such as name, sex or date of birth.  If CWF rejects a claim and sends back disposition code 55 with the 08 trailer containing Error Code 5052 when the beneficiarys personal characteristics do not match the HICN in accordance with the CWF matching criterion, contractors shall retur n the claim to the provider as unprocessable with the identifying beneficiary information from the submitted claim as follows: A/B MACs (A, HHH) shall
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accordance with the CWF matching criterion, contractors shall retur n the claim to the provider as unprocessable with the identifying beneficiary information from the submitted claim as follows: A/B MACs (A, HHH) shall return to provider (RTP) Part A claims.  These A/B MACs shall not mail an MSN for these claims.  A/B MACs (B) and DME MACs shall return as unprocessable Part B provider submitted claims.  The A/B MACs (B) and DME MACs shall not mail an MSN for these claims. When returning these claims as unprocessable, the shared processing system shall use Claim Adjustment Gr oup Code (Group Code) CO  Contractual Obligation, Claim Adjustment Reason Code (CARC) 16 -  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentati on.  At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance 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 with Remittance Advice Remark Codes (RARCs) MA27 -  Missing/incomplete/invalid entitlement number or name shown on the claim and N382 -  Missing/incomplete/invalid patient identifier.  For assigned and non- assigned Part B claims submitted by the beneficiary on the Form CMS -1490S or Form CMS -1500, A/B MACs (B) and DME MACs shall manually return the claim in accordance with Pub.100- 04, Chapter 1, Section 80.3.2 A. "Special Considerations."
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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
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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
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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)
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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;
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 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
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 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)