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MIR-2007-3AB, March 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Timeliness Standards for Processing Other-Than-Clean Claims
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers and Medicare Administrative Contractors (MAC) for services provided to Medicare beneficiaries
Provider Action Needed
This article is intended as informational only and is based on Change Request (CR) 5355, which provides requirements for all carriers and MACs for timeliness for processing “other-than-clean” claims.
Background
The Social Security Act (Section 1869(a)(2); http://www.ssa.gov/OP_Home/ssact/title18/1869.htm  ) mandates that the Centers for Medicare & Medicaid Services (CMS) process all “other-than-clean” claims and notify the individual filing such claims of the determination within 45 days of receiving such claims.
Claims that do not meet the definition of “clean” claims are classified as “other-than-clean” claims, and “other-than-clean” claims require investigation or development external to the contractor’s Medicare operation on a prepayment basis.
“Clean claim” means a claim that does not contain a defect requiring the Medicare contractor to investigate or develop prior to adjudication. Clean claims must be filed within the timely filing period (see the Social Security Act 1842(c)(2)(B); http://www.ssa.gov/OP_Home/ssact/title18/1842.htm ).
“Other Than Clean Claims” Any claim that does not meet the definition of clean claim above. These are complete claims that require manual intervention on the part of the contractor to be adjudicated.
CR 5355 instructs the Medicare contractor (carrier/MAC) to process all “other-than-clean” claims and notify the provider and beneficiary of the determination within 45 calendar days of receipt. See Medicare Claims Processing Manual (Publication 100-4, Chapter 1, Section 80.2.1; http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf  ) for the definition of “receipt date” and for timeliness standards for clean claims.
However, when the Medicare contractor develops the claim by asking the provider/supplier or beneficiary for additional information, the contractor will:
- Cease counting the 45-calendar days on the day that the contractor sends the development letter requesting the additional information, and
- Resume counting the 45-calendar days upon receiving the materials requested in the development letter from the provider/supplier and/or beneficiary.
EXAMPLE:
The Medicare contractor receives a claim on June 1, but does not send a development letter to the provider/supplier/ and/or beneficiary until June 5. In this situation, five of the 45 allotted calendar days will have already passed before the contractor requested the additional information.
Upon receiving the information back from the provider/supplier and/or beneficiary, the Medicare contractor has 40 calendar days left to:
- Process the claim, and
- Notify the individual that filed the claim of the payment determination for that claim.
CR 5355 instructs Medicare contractors to follow existing procedures relative to both:
- The length of time the provider/supplier and/or beneficiary is afforded to return information requested in the development letters, and
- Situations where the provider/supplier and or beneficiary does not respond.
For dates of receipt on and after July 1, 2007, Medicare contractors are instructed to process all “other-than-clean” claims and notify the beneficiary and the provider filing the claim within 45 calendar days of receipt, except when the contractor requests additional information from the provider/supplier or beneficiary, or to another contractor (e.g., the Coordination of Benefits Contractor, another claims processing contractor).
Instructions in CR 5355 do not apply to the following types of claims:
- Claims where the Social Security Administration blocks a beneficiary’s Health Insurance Claim Number (HIC),
- Claims the contractors are required to hold due to CMS instructions,
- Claims rejected by the translator process,
- Claims where the Medicare contractor is unable to process due to technical issues with Medicare’s beneficiary record or beneficiary identification issues, and
- Claims in development due to processing requirements (e.g., medical review), in Publication 100-8, the Medicare Program Integrity Manual ( http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage ).
Additional Information
For complete details, please see the official instruction issued to your carrier/MAC regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1173CP.pdf on the CMS Web site.
If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found on the CMS Web site at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip. 
Flu Shot Reminder
It’s Not Too Late to Give and Get a Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember - influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
MLN Matters Number: MM5355
Pub. 100-4, Transmittal# R1173CP, CR# 5355
Related CR Release Date: February 2, 2007
Effective Date: July 1, 2007
Implementation Date: July 2, 2007
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