Claims

20.2.2 – Claims (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) The CWF Claim Record is a record of a claim that the MAC has processed and is ready for payment or denial. It is submitted in daily files to the Host for approval. Prior to the approval CWF Host will send the claim to Fraud Prevention System (FPS) for review. Role of FPS: FPS interacts directly with the CWF Hosts and performs these functions: • Receive files submitted by CWF Hosts with claims approved for payment. • Process claims using proven predictive modeling tools to identify high risk claims. • Make a payment determination that is returned to the CWF Hosts for appropriate action. Only denied claims will be included in the returned file. The Host clears the claim record through regular CWF consistency edits, utilization edits and A/B crossover edits, in that order, and makes its approval, adjustment or rejection determination. The final determination is returned on a Claim Basic Reply Record. (See §20.3.2) Claim records can be of the following types: • Part B Claim Record: Part B bills are input on the HUBC record. • DMEPOS Claim Record: DMEPOS bills are input on the HUDC record. • Inpatient/Skilled Nursing Facility Claim Record: Inpatient hospital and SNF bills are input on the HUIP record. • Outpatient Claim Record: Outpatient bills are input on the HUOP record. • Home Health Claim Record: Home health bills are input on the HUHH record • Hospice Claim Record: Hospice bills are input on the HUHC record.