Integrated Data Repository (IDR) Claims Sourcing from Shared Systems

90 - Integrated Data Repository (IDR) Claims Sourcing from Shared Systems (Rev. 54, Issued: 10-01-08; Effective: 10-01-08; Implementation: 01-05-09) The CMS’ fraud investigation landscape is significantly different today than in the past as a result of program changes, such as the implementation of the Medicare Prescription Drug benefit, competitive selection of contractors responsible for claims administration and program integrity, such as Medicare Administrative Contractors (MACs) and PSCs, expansion of Medi- Medi and Recovery Audit Contractor (RAC) programs, and advent of the Medicaid Integrity Program (MIP). CMS recognizes the need to significantly enhance the use of technology to improve its collaborative fraud fighting efforts as well as to establish a modernized data analysis capability for all of Program Integrity. Today, most Program Integrity contractors have built their own data warehouses and/or avenues for collecting, processing, analyzing data which serves their own individual needs. These distributed, regional approaches to data analysis do not lend themselves to national analyses, do not represent best practices, and do not take advantage of the cost savings that a centralized data repository would provide. All of these functions can be better served through a comprehensive set of common data structures and modern tools that encourage collaboration and innovation. The IDR goal - through incremental releases - is to be the centralized data repository for all Medicare data. The Program Safeguard Contractors (PSCs) cannot currently use the IDR exclusively because the source of claims data is the National Claims History (NCH). The limited NCH data record is inadequate to support the extensive fraud, waste and abuse investigations that need to be performed by PSCs. The Shared Systems data are the required data source for Program Integrity. The CR initiates the acquisition of the Shared Systems data for the IDR. Once the IDR has the required Shared Systems data, Program Integrity and their contractors will increase their ability to detect potential fraud, waste and abuse. FISS shall provide, in electronic format, all claims output for all A/B MACs (A) or (HHH) and claim types on a daily basis at the claims header and detail level for each of the three identified lifecycle phases required. MCS shall provide, in electronic format, all claims output for all A/B MACs (B) and claim types on a daily basis at the claims header and detail level for each of the three identified lifecycle phases required. VMS shall provide, in electronic format, all claims output for all DME MACs and Certificates of Medical Necessity, as required with certain claims for payment, on a daily basis at the claims header and detail level for each of the three lifecycle phases required. The IDR Lifecycle Phase I is defined as the claim upon enumeration. The IDR Lifecycle Phase II is defined as the claim immediately after CWF adjudication. The IDR Lifecycle Phase III is defined as the claim once financial information has been posted to it.