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
• Performs outside development as a result of a CWF edit.
