Communication between Host and MAC’s Jurisdiction Sector

20.1 - Communication between Host and MAC’s Jurisdiction Sector (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) The local CWF database for each sector resides at a Host. Each A/B and DME MAC within the sector is linked to its Host's database. Communication between them is electronic, with claims ready for payment or denial communicated to the Host, and adjustments, approvals, rejects, and informational trailers returned from the Host via a daily process. The A/B and DME MAC’s usually initiates this process. On occasion, the CWF Host will initiate an "unsolicited response" to the A/B and DME MAC’s as a result of a new claims action that affects a previously processed claim action. Claims are processed by CWF in the same order that they are received, regardless of the dates of service or receipt date. This first-in-first-out method of processing requests for payment facilitates prompt handling of claims. Role of CWF Hosts: • Responsible for executing a common set of CWF software modules to maintain Beneficiary databases by adding or updating Beneficiary entitlement information provided by CMS o These updates are processed by the enrollment database (EDB) and continue to update CWF Host records as the beneficiary's entitlement changes. • Perform consistency; utilization, A/B cross over and duplicate edit checks to provide authorization for MAC’s to pay claims; • Providing and controlling linkage of the MAC’s in the sector to the Host; Controlling and monitoring telecommunications network operations • Supplying MAC’s with inquiry and transmission software necessary to communicate with the Host and make full use of the CWF data inquiry features; • Receiving, installing, testing, and operating the CWF software system, including all changes developed by CWFM; Role of A/B and DME Medicare Administrative Contractors (MACs): • Submission of claims via telecommunication in batch mode to a CWF Host for validation and payment approval; • Receive, control, and enter claims into an automated processing system. • Review, edit, and adjudicate claims through CWF system for determination of eligibility, coverage, and pricing. • Submission of online inquiries to a CWF Host to determine Beneficiary enrollment status and eligibility • Submit claims to the CWF Host for pre-payment validation and authorization. • Issue payments to Providers or deny/develop claim is rejected by CWF; - Issue Explanation of Medicare Benefits and payments to Beneficiaries.