Classification of Claims for Counting

120.1 - Classification of Claims for Counting (Rev. 175, Issued: 10-28-10, Effective: 04-01-11, Implementation: 04-04-11) All claims data entered on page one of the performance report must represent counts of claims (real and replicate) as defined in the Medicare Claims Processing, Chapter 1, General Billing Requirements. The carrier includes in column (i) the following types of claims: CMS-1500s, CMS-1490s, and CMS-1491s. Of these claims forms, it reports the assigned in column (ii) and the unassigned in column (iii). It includes any claims where processing has been suspended due to CMS directives since they are still part of its claims workload. NOTE: It does not count assigned claims received from physicians/suppliers if they are incomplete, incorrect, or inconsistent and consequently returned for clarification. It does not have to control such claims. Throughout its process, it includes the date material is received on all claims (real and replicate). It shows identifying numbers or codes on all replicate claims through the processing system so that they can be counted and reported separately in Part A. The carrier reports claims as received in the month the claim is received in its mailroom with the following exceptions: • Additional real claims resulting from a split; and • Claims identified as replicates. Split and replicate claims, although carrying the dates the materials were originally received, are to be counted as receipts for the month in which they are recognized by the carrier's system as created (i.e., split or identified as replicate) for purposes of this report. EXAMPLE: The carrier splits a claim received in the reporting month into two claims because the total number of line items exceeds its system's line item limitation. If it can recognize this split when it occurs, it reports two claims in "Total Claims Received During Month" and in "Net Number of Claims Received" (lines 4 and 6, respectively) in Part A of the report. It reports both claims in Part A. After processing the split (replicate) claim, it reports it in Part A under "Replicate Claims Processed" (line 16), as well as under "Total Claims Processed" (line 15). If its system does not indicate when the split occurs, it counts the new claim as a receipt for the month in which the system allows it to be recognized, although the date claims materials were originally received must be carried forward and remain unchanged. The carrier counts claims received near the end of the reporting month but placed under computer control in the following month as received in the reporting month. It obtains this count by a physical inventory or by computer count.