B CUECs – Claims Processing

30.9.2 – B CUECs – Claims Processing (Rev. 331, Issued: 11-15-19, Effective: 10-01-19, Implementation: 12-17- 19) B – Control Objective Number B – CUEC Description B.4 Updates to the Sanction/Reinstatement file are provided to the Contractors on a monthly basis. B.4 CMS sends Denial of Payment for New Admissions (DPNA) letters indicating a facility is not in compliance. B.5 CMS provides guidance on the claims appeal process and provides accurate and timely notification of appeal status. B.4, B.5 CMS provides the Office of Inspector General/Supplemental Medical Review Contractor requests to the Contractor. B.6 CMS issues annual and quarterly change requests timely and accurately for CMS applied software pricing modules and FISS/MCS changes. B.8 Claims are properly aged from the actual receipts date to the actual date of payment in compliance with CMS instructions. Receipt dates for claims are date stamped and entered into the claims processing system by CMS maintainer organizations. The CMS maintainer organizations are responsible for completely and accurately logging and entering receipt date of claims into the claims processing system. B – Control Objective Number B – CUEC Description B.9 The Shared System Maintainers will provide guidance and controls to track and adjudicate claims, complete base system edits, process Informational Unsolicited Responses (IURs), and analyze/model data from the warehouse to allow detection and prevention of fraud at the MACs. ALL CMS deploys and manages CMSNET, a private communication network that allows data to be encrypted during the transmission to prevent any unauthorized sources from intercepting data. The Contractors utilize CMSNET to transmit data with the Enterprise Data Centers (EDCs) and other business partners that utilize CMSNET. ALL CMS accurately and timely communicates mandated regulatory requirement changes and internal policy changes. ALL CMS ensures CWF and the Beneficiary Data Streamlining (BDS) have accurate and timely data. End Section 30.9.2 – B CUECs – Claims Processing: Back to Table of Contents