Body of Report

30.3 - Body of Report (Rev. 6, 08-30-02) A3-3894.3 SECTION E (1): CLAIMS PROCESSING TIMELINESS - ALL CLAIMS Pages 2-11 of the CMS-1566 include data on intermediary activity in processing all bills to completion during the reporting period. The intermediary counts the bill as processed to completion on the "scheduled payment date," which is the date the check it issued is mailed, deposited by it in the provider's account, or transferred electronically. For PIP bills and no payment bills, the "scheduled payment date" is the date for payment bills in the same adjudication batch. Base data shown on reliable counts of all bill processing activity. The intermediary does not estimate bill counts. It reports data on initial bills only (including demand bills and no-pay bills submitted by providers with no charges and/or covered days/visits). It does not include: • Bills received from institutional providers if they are incomplete, incorrect, or inconsistent and consequently returned for clarification. Individual controls are not required for these bills; • Adjustment bills; • Misdirected bills transferred to a carrier or another intermediary; • HHA bills where no utilization is chargeable and no payment has been made, but which the intermediary requested only to facilitate record keeping processes. (There is no CMS requirement for HHAs to submit no payment non-utilization chargeable bills); • Bills paid by an HMO and processed by the intermediary, and • HH PPS RAPs with three-digit classification code 3-2-2 or 3-3-2 with dates of service 10/01/2001 and greater. Apart from these exceptions, it includes in the report all bills (including PIP, EMC, provider and independent RHC, as well as HMO bills paid by it) processed to completion (i.e., paid bills, complete denials, and no payment bills) in the reporting month. It reports bills in the month the scheduled date of payment falls. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for the definition of scheduled payment date for all bills, including PIP and no payment bills. "Clean" bills are those that do not require investigation or development external to the intermediary operation on a prepayment basis. Bills that do not meet the definition of “clean” are "other" bills. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for examples of "clean" and "other." Bills paid are those for which some payment was made (i.e., payment greater than zero). Bills not paid are those for which no payment was made (i.e., bill charges applied completely toward deductible or fully denied). On each page 2-11 (there is a separate page for each type of bill category listed below), the intermediary reports: • In column 1, the total number of bills processed to completion; • In column 2, the number of "non-PIP clean" bills paid; • In column 3, the number of "non-PIP other" bills paid; • In column 4, the number of "PIP clean" bills paid; • In column 5, the number of "PIP other" bills paid; • In column 6, the number of "clean" bills not paid; • In column 7, the number of "other" bills not paid; and • In column 8, the number of "clean" and "other" bills processed to completion, which were received via electronic media from providers or their billing agencies and read directly into the intermediary claims processing system. The intermediary does not count on this line bills that it received in hardcopy and entered using an OCR device. It does not count any bills received in hardcopy and transformed into electronic media by any entity working for it directly or under subcontract. For each category, it shows the number processed to completion on the line corresponding to the number of days from receipt by it to the scheduled date of payment or other final action, if a no-pay bill. See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for definition of receipt date. NOTE: For bills received by tape, the date the intermediary receives the tape should be used as the receipt date and not the date the tape passes the edits. To calculate the processing time for a claim, the intermediary 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 to the Julian date of completion 365 (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 one day. This definition applies to all lines of the report, including line 39. On line 39 the intermediary reports the mean processing time (PT) to one decimal place for each column. To calculate the mean PT, it adds the processing times for all the bills shown in lines 1-37 of that column and divides by 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 must use the processing times for the individual claims as explained below to make this calculation. Mean Processing Time Calculation 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. • Sum the result for each claim into a total 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 91103 91133 30 1 B 91105 91206 101 2 C 91115 91177 62 3 D 91120 91213 93 4 E 91122 91215 93 5 F 91130 91223 93 6 Total Days = 30 + 101 + 62 + 93 + 93 + 93 = 472 Mean = 472/6 = 78.6666 = 78.7 The intermediary completes the report for each bill type: • Inpatient Hospital - Of the bills reported on the "All Claims" page, it shows on page 2 data on the number of CMS-1450s submitted by hospitals for inpatient services with the following two-digit classification codes in Form Locator 4: 1-1 (inpatient hospital); and 4-1 (Religious Nonmedical Health Care Facility - Hospital-inpatient), • Outpatient - Of the bills reported on the "All Claims" page, it shows on page 3 data on the number of CMS-1450s submitted by hospitals and SNFs for outpatient services with the following two-digit classification codes in Form Locator 4: 1-3 (hospital-outpatient); 2-3 (SNF-outpatient); 4-3 (Religious Nonmedical Health Care Facility - Hospital-outpatient); 5-3 (Religious Nonmedical Health Care Facility - SNF-outpatient); and 8-3 (hospital-outpatient surgical procedures - ASC), • SNF - Of the bills reported on the "All Claims" page, it shows on page 4 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 1-8 (hospital swing-bed); 2-1 (SNF-inpatient); 2-8 (SNF-swing- bed); and 5-1 (Religious Nonmedical Health Care Facility - SNF-inpatient), • HHA - Of the bills reported on the "All Claims" page, it shows on page 5 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 3-2 (HHA-Part B visits and use of DME); 3-3 (HHA-Part A visits and DME); and 3-4 (HHA-other-Part B benefits), • Hospice - Of the bills reported on the "All Claims" page, it shows on page 6 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 8-1 and 8-2 (Hospice), • CORF - Of the bills reported on the "All Claims" page, it shows on page 7 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 7-4 (Other Rehabilitation Facility) and 7-5 (Comprehensive Outpatient Rehabilitation Facility), • ESRD - Of the bills reported on the "All Claims" page, it shows on page 8 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 7-2 (hospital-based or independent renal dialysis facilities), • Lab (All referred outpatient diagnostic services) - Of the bills reported on the "All Claims" page, it shows on page 9 data on the number of CMS-1450s with the following two-digit classification codes in Form Locator 4: 1-4 (Hospital-Other- Part B benefits); and 2-4 (SNF-Other-Part B benefits), • Other - Of the bills reported on the "All Claims" page, it shows on page 10 data on the number of CMS-1450s not included in the previous eight bill categories, including provider and independent RHC bills, and • All Claims - On page 11 it includes all bills processed to completion during the reporting month. SECTION E(2): CLAIMS PROCESSING TIMELINESS - EMC CLAIMS AND ADJUSTMENTS FOR CPEP CPT CALCULATIONS Pages 12-21 of the CMS-1566 the intermediary includes data on the non-PIP bills paid during the month they were received via electronic media. The basic instructions and definitions that apply to pages 2-11 (see above) also apply to pages 12-21. For each bill type, it reports the following information: • Column 1 - The intermediary reports the number of EMC claims that were included in column 2 (paid non-PIP clean) for the corresponding bill type on pages 2-11. • Column 2 - The intermediary reports the number of EMC claims that were included in column 3 (paid non-PIP other) for the corresponding bill type on pages 2-11. For each bill type on pages 12-21, it reports the following adjustments for CPEP CPT calculations: CWF - Claims that were beyond its control due to CWF. (See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements for definition of claims meeting this criteria.) A. The number of EMC non-PIP clean claims paid beyond the EMC ceiling. B. The number of paper non-PIP clean claims paid beyond the paper ceiling. C. The number of all claims processed beyond 60 days. WAIVER - Non-PIP claims paid under the claims payment floor for which the intermediary had a waiver from CMS. D. The number of EMC non-PIP clean claims paid under the EMC floor. E. The number of paper non-PIP clean claims paid under the paper floor. F. The number of EMC non-PIP claims (clean and other) paid under the EMC floor plus the number of paper non-PIP claims (clean and other) paid under the paper floor.