Critical Case Procedure - Establishing Entitlement

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.