Claims that do not meet the definition of “clean” claims are “other” claims.
“Other” claims require investigation or development external to the carrier or
FI’s Medicare operation on a prepayment basis. “Other” claims are those that
are not approved by CWF for payment that the FI identifies as requiring outside
development. Examples are claims on which the provider’s FI/carrier:
• Requests additional information from the provider or another external source.
This includes routine data omitted from the bill, medical information, or
information to resolve discrepancies;
• Requests information or assistance from another contractor. This includes
requests for charge data from the carrier, or any other request for information
from the carrier;
• Develops Medicare Secondary Payer (MSP) information;
• Requests information necessary for a coverage determination;
• Performs sequential processing when an earlier claim is in development; and
Data Element Requirements Matrix
The matrix (See Exhibit 1) specifies data elements, which are required, not
required, and conditional for FI claims. The matrix does not specify item or
field/record content and size. Refer the electronic billing instructions (UB-04
and ANSI 837) on the CMS Web site to build these additional edits. If a claim
fails any one of these “content” or “size” edits, the FI returns the
unprocessable claim to the supplier or provider of service.
The FIs must provide a copy of the matrix listing the data element
requirements, and attach a brief explanation to providers of service and
suppliers. The matrix is not a comprehensive description of requirement that
need to be met in order to submit a compliant transaction.
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