Part D (1) - Claims Processing Timeliness - All Claims

150 - Part D (1) - Claims Processing Timeliness - All Claims (Rev. 12456; Issued:01-11-24; Effective: 07-01-24; Implementation:07-01-24) Pages 2-9 of the CMS-1565 include data on its activity in processing all claims to completion during the reporting period. A claim is counted as processed to completion on the scheduled payment date, which is the date the check is mailed, deposited in the provider’s account, or transferred electronically. For non-paid claims, the date of completion is the date the MSN or other notice of final action on the claim is mailed. Data shown must be based on reliable counts of all claims (real and replicate) processing activity. The A/B MAC (B) does not estimate claim counts. It reports only data relating to initial claims (real and replicate) actions. It does not report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim actions. "Clean" claims are defined as those that do not require investigation or development external to the A/B MAC (B)’s operation on a prepayment basis. Claims which do not meet the definition of "clean" are "other" claims. Claims paid are those for which some payment was made (i.e., payment greater than zero). Claims not paid are those for which no payment was made (i.e., claim charges applied completely toward deductible or fully denied). On pages 2-9, the A/B MAC (B) reports: • In column 1, the total number of claims processed to completion; • In column 2, the number of "clean" claims paid; • In column 3, the number of "other" claims paid; • In column 4, the number of "clean" claims not paid; • In column 5, the number of "other" claims not paid; and • In column 6, the number of "clean" or "other" claims processed to completion, which were received via electronic media from providers or their billing agencies and read directly into the A/B MAC (B)’s claims processing system. The A/B MAC (B) does not count on this line claims that it received in hardcopy and entered using an OCR device. It does not count any claims received in hardcopy and transformed into electronic media by any entity working for it directly or under subcontract. The data in lines 1 through 37 of pages 2 through 9 represent the number of claims processed in the number of days shown on that line, counting from the date of receipt. Line 38 represents the sum of lines 1-37. The date of receipt is defined for hard-copy and magnetic tape claims as the date of receipt in the mailroom. For EMC billed via terminal or equivalent, it is the date the claim passes all front-end edits. For split claims, whether required or replicate, the date of receipt is the date of receipt of the original claim material, not the date of the split. To calculate the processing time for a claim, the A/B MAC (B) subtracts the Julian receipt date from the processed to completion Julian date. When the processed to completion date falls in the year following the year of receipt, it adds 365 to the Julian date of completion (or 366 if the year of receipt is a leap year). If a claim is processed to completion on the same day it is received, the processing time is 1 day. This definition applies to all lines of the report, including line 39. On line 39, the A/B MAC (B) reports the mean processing time (PT) to one decimal place for each column. To calculate the mean PT, it adds the processing times for the claims shown in line 38 of that column, and divides by the number in line 38. It does not use the categories on the report to calculate the mean PT. Because of the aggregation of claims in lines 34-37, it uses the processing times for individual claims, as explained below, to make this calculation. Mean PT Calculation for All Claims - To determine the mean PT for all claims: • Subtract the Julian date of receipt from the Julian date of payment or equivalent action for those not paid for each claim. • Accumulate the result to cell counter for number of days for all claims. • Divide this result by the total number of claims. • Round to one decimal place. EXAMPLE: Claim Julian Date Receipt Paid Counter by Days Counter by Claims A 87103 87133 30 1 B 87105 87206 101 2 C 87115 87177 62 3 D 87120 87213 93 4 E 87122 87215 93 5 F 87130 87223 93 6 Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472 Mean = 472/6 = 78.6666 = 78.7 The A/B MAC (B) completes the report for each of the following claim types: Page 2. Assigned Physician - It shows the number of assigned claims included on page 9 which involved services billed by physicians. Physicians are identified by specialty codes 01-14, 16-30, 33-41, 44, 46, 48, 66, 70, 72, 76-79, 81-86, 90-94, 98, 99, C0, or C3, C5, C6, C7, C8, C9, D3 D4, D7, D8, E1, E2, E3, E4, E5, E6, E7, E9, F1, F2, F3, F4, F5, F6. Page 3. Assigned DME - It shows the number of assigned claims included on page 9 which involved services billed by DME suppliers. Page 4. Assigned Lab - It shows the number of assigned claims included on page 9 which involved services billed by an independent laboratory. Independent laboratories are identified by specialty code 69. Page 5. Assigned Ambulance - It shows the number of assigned claims included on page 9 which involved services billed by ambulance service suppliers. Ambulance service suppliers are identified by specialty code 59. Page 6. Assigned Other - It shows the number of assigned non-physician claims included on page 9 but not represented on pages 3, 4, or 5. Page 7. Unassigned - It shows the number of unassigned claims (real and replicate) included on page 9. Page 8. Participating Physician - It shows the number of claims included on page 9 involving services rendered by physicians enrolled in the Medicare Physician/Supplier Participation Program. Page 9. All Claims - It shows the total number of claims (real and replicate) processed during the month.