Contractor Responsibility

50.10.2.2 - Contractor Responsibility (Rev. 2803, Issued: 10-28-13, Effective: 09-17-13, Implementation: 09-17-13) A/B MACs and DME MACs will be required to establish dedicated fax lines and Post Office boxes for provider/claim submitters to utilize for providing the additional documentation. A/B MACs and DME MACs will provide the education and outreach support to provider/claim submitters on how to utilize the PWK process. The A/B MACs and DME MACs shall provide the coversheet to the provider/claim submitter in whatever manner they feel provides the most effective and efficient method for providing the cover sheet. If the coversheet is not completely and accurately filled out, the A/B MACs and DME MACs shall return the coversheet to its originator. A/B MACs and DME MACs shall indicate that the cover sheet is being returned for incomplete/inaccurate completion and the documentation is not being taken into consideration for the purpose of claims adjudication. The A/B MACs and DME MACs are free to choose the method of returning the cover sheet which they feel best suits their business operation. It is important to note that the A/B MACs and DME MACs are not required to return the additional documentation along with the cover sheet. The A/B MACs and DME MACs are to follow their current correspondence retention requirements and processes regarding the controlling and storage of the additional documentation (whether the documentation is utilized for claims processing assessment or not). If the provider/claim submitter cannot be identified by the A/B MACs and DME MACs thus making it impossible to return the cover sheet, the documentation will be imaged and sent off for storage as per normal CMS correspondence retention requirements. Documentation submitted late will not be considered for adjudication but will be imaged and sent off for storage as per normal CMS correspondence retention requirements. Additional documentation received by A/B MACs and DME MACs via the PWK process will be imaged and made available for view and/or retrieval by claims examiners/medical review staff. A/B MACs and DME MACs staff adjudicating claims will only review PWK data when the claim encounters an edit/audit requiring additional documentation. The presence of the PWK indicator within the shared system will alert contractor staff that there is additional documentation which potentially may be used to adjudicate the claim. It is important to note that the simple presence of the PWK on a claim will not cause the claim to suspend. When A/B MACs and DME MACs staff encounters an edit or an audit within the shared system that could be affected by additional documentation, they will first look to see if a PWK was submitted on the claim. If there is a PWK present, they will retrieve the appropriate additional documentation from their imaging system and review it. If the additional documentation contains the needed information, the A/B MACs and DME MACs will adjudicate the claim accordingly and flag the claim as dirty. If the additional documentation does not contain the needed information, the claim will then be handled according to the normal CMS business procedures and policies in place at the time. Regardless of whether or not the PWK additional documentation is utilized in adjudicating the claim, the waiting days will not count against the contractor’s claims processing timeliness (CPT).