Process Change – No Longer Returning Suspended Claims for Correction Upon Provider Request
Beginning February 1, 2007, Cahaba will no longer return suspended claims for correction to a provider’s Return to Provider (RTP) file upon the provider’s request. Until this effective date, Cahaba will only return suspended claims for correction upon a provider’s request in the following circumstances:
- The request is made the same day the provider submitted the claim or worked it out of RTP; or
- The claim is in FISS status/location (S/LOC) S B9000, (except claims that have been reviewed by Medical Review).
If claims are submitted with incorrect, missing or inappropriate information, providers may correct the claims after FISS returns the claims to the RTP S/LOC T B9997. If the claim does not go to the RTP file, providers can still change the information after the claim has finalized (S/LOC P B9997 and R B9997) by submitting adjustments and cancellations, when appropriate.
One of the reasons why this process change is occurring is in preparation for additional data that will be made available through the Comprehensive Error Rate Testing (CERT) program. CERT is a quality assurance program established by the Centers for Medicare & Medicaid Services (CMS) to ensure that contractors are paying claims correctly according to Medicare regulations.
There are currently three different types of data that are calculated through the CERT program for fiscal intermediaries (FIs), with a fourth one (the Provider Compliance Error Rate) to be calculated in the future. The Provider Compliance Error Rate reveals how well providers prepare claims for processing prior to their submission to Medicare before any edits in the Fiscal Intermediary Standard System (FISS) are applied.
Providers, therefore, are encouraged to make sure the information on their claims is complete, appropriate and according to Medicare regulations prior to submitting them to Cahaba.
In addition to a high Provider Compliance Error Rate, providers are negatively impacted by the consequences of incomplete, inappropriate and missing claim information, which costs time and money by creating the need for staff to re-work or re-submit claims, as well as contributes to Medicare payment delays and cash flow interruption. The Medicare program also is negatively impacted due to increasing the cost to process Medicare claims.
Please ensure that your staff is aware of this process change prior to it taking effect in February 2007. If you have questions regarding this process change, please contact a Customer Service Representative at the appropriate telephone number found on the “Contact Us” page.
Page last updated: Dec. 21, 2006
