B Controls – Claims Processing

50.2 – B Controls – Claims Processing (Rev. 331, Issued: 11-15-19, Effective: 10-01-19, Implementation: 12-17- 19) B – Control Number Control Objective – Claims Processing B.1 The Medicare claims processing system tracks each claim from receipt to final resolution. B.2 Controls provide reasonable assurance that fee-for-service information system edits and / or validations are configured in accordance with CMS guidelines including: • Management maintains a current baseline of edit configurations in accordance with CMS guidelines. • Management assesses the current configuration of edits against the baseline periodically. • For misconfigured edits Management remediates the configuration in a timely fashion. • Management reports results of reconciliations / reviews to CMS periodically. (Maintainer Only. Applicable for A-123 Reviews) B.3 The system generates an audit trail with respect to each claim, adjustment, or other related transaction. Such audit trail shall include the results of each applicable claim edit. (Maintainer Only. Applicable for A-123 Reviews) B.4 Each claim is adjudicated in accordance with CMS instructions. B.5 Claims are reopened in accordance with CMS guidelines and readjudicated in accordance with CMS instructions. B.6 Claim payment amounts are calculated in accordance with CMS instruction. Fee schedules are properly received, logged, and changed in the system and monitored, and applied in accordance with CMS instructions. B.7 The system shall identify and deny duplicate claims in accordance with CMS instructions. (Maintainer Only. Applicable for A-123 Reviews) B.8 Claims are properly aged from the actual receipt date to the actual date of payment in compliance with CMS instructions. B.9 The system shall detect apparent fraudulent or abusive practices in accordance with CMS instructions. Personnel are trained to detect fraudulent and abusive practices and, in accordance with CMS instructions, to deter such practices. Any such apparent fraudulent or abusive practices as are identified are documented and reported in accordance with CMS instructions. End Section 50.2 – B Controls – Claims Processing: Back to Table of Contents