Reject and Unsolicited Response Edits

110.2.1 - Reject and Unsolicited Response Edits (Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary’s Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. A. Reject Edits When CWF receives a bill from the SNF that shows that a beneficiary became a resident of a SNF, that SNF stay is posted to history. Effective April 2002, for claims processed and adjusted with dates of service on or after April 1, 2001, CWF will apply the reject edits to any claims received after the SNF stay is posted that have dates of service during the periods the beneficiary is shown to have been a resident of the SNF based on that first SNF bill. These claims can be correctly rejected since it will be clear that the beneficiary was in the SNF during those spans that were shown on the SNF claim. This process will repeat when the next SNF bill is received. The process will continue until CWF posts a discharge date, date of death, or the covered number of SNF days has been used. Based on the CWF line item rejects, A/B MACs (B)/DME MACs must deny assigned and unassigned services they have been billed that should have been consolidated and paid by the SNF and/or billed to the A/B MAC (A). Appeals rights must be offered on all denials. Shared systems must develop, and along with A/B MACs (B)/DME MACs must implement, an automated resolution process whereby when they receive a reject from CWF, they must pay those services correctly billed and only deny those services on the claim incorrectly billed to them. B. Unsolicited Response Edits Effective July 1, 2002, CWF implemented the unsolicited response edit based on the same coding files made available for the reject edits. Upon receipt of a Part A SNF claim at CWF, CWF searches paid claims history and compares the period between the SNF from and through dates to the line item service dates of the claims in history. It then identifies any services within the dates of the SNF stay that should have been subject to consolidated billing and should not have been separately paid by the A/B MAC (B)/DME MAC. The CWF generates an unsolicited response, with a trailer that contains the identifying information regarding the claim subject to consolidated billing and a new trailer containing line item specific information that identifies all the individual services on that claim that fall within the SNF period. The unsolicited response provides all necessary information to identify the claim, including Document Control Number, Medicare beneficiary identifier, beneficiary name, date of birth, and beneficiary sex. CWF electronically transmits this unsolicited response to the A/B MAC (B)/DME MAC that originally processed the claim with consolidated services. These unsolicited responses are included in the CWF response file. The unsolicited responses in that file for claims to be adjusted for consolidated billing are identified with a unique transaction identifier. The previously paid claim is not canceled and remains on CWF paid claims history, pending subsequent adjustment. Upon receipt of the unsolicited response, the shared system software reads the line item information in the new trailer for each claim and performs an automated adjustment to each claim. Services subject to consolidated billing must be denied at the line level. The adjusted claims must then be returned to CWF, so that the claim on CWF paid claims history is replaced with the adjusted record. A/B MACs (B)/DME MACs must return the claims with entry code 5. Both the covered and the non-covered services must be returned to CWF on the adjustment claim. When CWF adjusts the claim on history, the deductible is updated on the beneficiary’s file and the corrected deductible information is returned to the A/B MAC (B)/DME MAC in trailer 11. To recover any monies due back to Medicare resulting from these denials, A/B MACs (B)/DME MACs must follow the criteria in current overpayment recovery for the policy guidelines for furnishing demand letters and granting appeals rights. In cases where all services on the claim are identified in CWF as subject to consolidated billing, the claim is adjusted by the standard system to line item deny all the services on the claim. These fully non-covered claims must be returned to CWF, in order to reflect the denial actions in CWF paid claims history and to update the information in CMS’s national claims history file. A/B MAC (B)/DME MAC systems must employ existing processes for the submission of fully non-covered claims.