Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 977 Date: October 27, 2011

Transcription

1 anual ystem Pub One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 977 Date: October 27, 2011 hange equest 7601 UBJT: nhancements to the ecovery udit ass djustment/eporting Process in the iscal ntermediary hared ystem (). UY O NG: The directed enhancement of the existing file-based ecovery udit mass adjustment/reporting process in the iscal ntermediary hared ystem () via hange equests 6928, Transmittal 673 dated pril 16, 2010 (July 2010) and 7272, Transmittal 904 dated June 8, 2011 (July 2011); this directs a variety of additional utility and usability enhancements. TV DT: pril 1, 2012 PLNTTON DT: pril 2, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =VD, N=NW, D=DLTD-Only One Per ow. /N/D PT / TON / UBTON / TTL N/. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

2 V. TTNT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

3 ttachment One-Time Notification Pub Transmittal: 977 Date: October 27, 2011 hange equest: 7601 UBJT: nhancements to the ecovery udit ass djustment/eporting Process in the iscal ntermediary hared ystem () ffective Date: pril 1, 2012 mplementation Date: pril 2, GNL NOTON. Background: The directed enhancement of the existing file-based ecovery udit mass adjustment/reporting process in the iscal ntermediary hared ystem () via hange equests 6928 (Transmittal 673 dated pril 16, 2010) and 7272 (Transmittal 904 dated June 8, 2011); this directs a variety of additional utility and usability enhancements. B. Policy: The nationwide ecovery udit program was mandated under Division B, Title, ection 302 of the Tax elief and ealthcare ct of ll references to the mass adjustment process in the business requirements table refer to the file-based process, not the co-existing online process.. BUN QUNT TBL Number equirement esponsibility / B D The mass adjustment input layout shall include new fields for admission type, admission source and provider names, as well as the ability to capture fractional units and new claim-/line-level filler space to facilitate future expansion. This information will be provided on the input file by the ecovery uditor. NOT: The description of the workload D in the file headers has been clarified to Primary workload D of D processing region djusted Principal Diagnosis is also captured in the adjusted diagnosis section of the input layout and shall be removed as a separate field. hared- ystem aintainers V W OT

4 Number equirement esponsibility / B D shall use the new pecial ction flag on the input layout to identify adjustments that shall be handled as exceptions to normal automated processing shall allow ecovery uditors to use pecial ction ode to create adjustments that shall immediately suspend for further action by the claim processing contractor. NOT: Use of this functionality shall be coordinated with the contractor and shall be limited to adjustments that cannot be completed through the existing automated process (i.e., those where the field being changed is not on the input layout). s intent is to reduce contractor burden by eliminating the need to key information that can be copied from the original claim; ecovery uditors shall submit all data that would otherwise be required for automated adjustment ontractors shall be able to segregate these adjustments for special attention and/or convenient selection via a specific location or similar functionality to allow for easy access by contractors. This can be accomplished by storing these adjustments in a separate location on to allow for ease of finding the adjustments by contractors The Overpayment or Underpayment field on the mass adjustment outcome layout shall be renamed to djustment Outcome, with the following valid codes: O = Overpayment U = Underpayment N = No change in payment ass adjustment outcome files shall include the revised DG code shall begin sending ecovery uditor-initiated adjustments to Periodic nterim Payment (PP) provider claims to GL via the 837 interface. hared- ystem aintainers V W OT

5 Number equirement esponsibility / B D GL shall create appropriate receivables/payables and demand letters for the received adjustments offsetting amounts due against PP payments as with adjustments to non-pp providers claims The Provider tatistical and eimbursement (P&) ystem shall recognize ecovery uditor-initiated adjustments (created under B and ) and shall segregate those adjustments from the reconciliation process to ensure that overpayments and underpayments are only corrected once The maintainers shall make any changes necessary to facilitate B is not required to resume Legacy P& data collection for ecovery uditor-initiated adjustments, per 7487 (Transmittal 929 dated ugust 1, 2011). hared- ystem aintainers V W OT GL / Provider udit. POVD DUTON TBL Number equirement esponsibility / B D None. hared- ystem aintainers V W OT V. UPPOTNG NOTON ection : or any recommendations and supporting information associated with listed requirements:

6 -ef equirement Number N/ ecommendations or other supporting information: ection B: or all other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Jennifer lmezzi or ) Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. ttachment

7 evised input files (header) ield # ield Name tart nd Length Values/comments 1 ile type NPUT 2 iller ile format version iller ecord count Number of records in file, not including header; zero fill 6 iller ecord length iller ile creation date YYYYDD 10 iller ource D Primary workload D of D processing region 12 iller egion egion associated with originating 14 iller NOT 1: ll fields in all layouts are left justified/space filled unless otherwise indicated. NOT 2: nput and outcome files shall be space filled record lengths will not vary with line counts. NOT 3: ed/bold/italic represents changes from the existing 7272 (Transmittal 904 dated June 8, 2011) layout; field names from original 5494 (Transmittal 267 dated arch 30, 2007) process have been removed.

8 ield # 1 // workload number number/prefix/suffix DN Provider NP Provider O/N laim start date laim end date laim paid date ield Name tart nd Length omments 9 pecial action code evised input files (content) t time of original processing; may differ from current number (i.e., Title V vs. ) to force suspension; 10 djustment reason code () 11 laim denial reason code djusted admission date djusted admission type djusted admission source djusted patient discharge status 16 djusted discharge date djusted DG djusted admitting diagnosis djusted diagnosis/po djusted diagnosis 7 djusted PO indicator 1 69 djusted attending provider NP ttending provider last name ttending provider first name djusted operating provider NP Operating provider last name even diagnosis bytes (D-9 w/filler or D-10 eventually) plus a PO indicator in the 8th position

9 74 Operating provider first name djusted other provider NP Other provider last name Other provider first name djusted principal procedure djusted principal procedure date evised input files (continued) ield # 80- djusted additional 127 procedures djusted procedure 7 djusted procedure date iller ount of revenue codes ield Name tart nd Length omments 130+ evenue code to submit all revenue/ P/PP codes, whether changed or not, including the 0001 summary line (total charges, covered charges and non-covered charges). laims with 6+ N segments must be adjusted manually. evenue code 4 P/PP 5 odifier 1 2 odifier 2 2 odifier 3 2 odifier 4 2 odifier 5 2 Units 10 NNNNNNNDDD (implicit decimal) ate 9 NNNNNNDDD (implicit decimal) Date of service 8 YYYYDD evised charges 9 evised covered charges 9 Nominal charges for revised allowable units (linear projection from original amount) with implicit decimal: NNNNNNNDD. shall submit partial line denials as two separate lines, one with covered charges and one with non-covered charges. stimate of covered amount based on allowable units; to calculate exact amounts payable.

10 evised non-covered charges 9 Line denial reason code 5 iller 25 orresponding estimate of non-covered amount based on allowable units. xample: Original djusted Line Number evenue ode P Qty Non- harges overed overed Line Number evenue ode P Qty harges overed Non- overed

11 evised initial outcome files (header) ield # ield Name tart nd Length Values/comments 1 ile type OUT 2 iller ile format version iller ecord count Number of records in file, not including header; zero fill 6 iller ecord length iller ile creation date YYYYDD 10 iller ource D Primary workload D of D processing region 12 iller egion region of adjusted claims 14 iller

12 evised initial outcome files (content) ield # ield Name tart nd Length omments 1 djustment outcome O to indicate overpayment; U for underpayment; N for no change (adjustment complete, pricing remains the same); 2 // workload number Workload D number of the contractor processing the adjustment. 3 Original contractor workload number The workload D of the contractor that originally processed the claim, which may differ from that of the contractor that is processing the adjustment (i.e., #12345 adjusts a claim originally processed by #54321). 4 Business egment dentifier Original DN djustment DN Provider NP Provider legacy number (O/N) 9 Original claim paid date djustment finalization date djusted DG Original claim paid amount Unsigned w/explicit decimal: NNNNNNNNN.DD 13 djusted claim paid amount Unsigned w/explicit decimal 14 Total error Unsigned original adjusted amounts w/decimal P/PP code of the specific service adjusted by the, or other codes that changed as a result of the s adjustment; up to 450 codes per record. These fields help determine the amount of recoveries attributable to specific services versus associated findings (i.e., other lines that re-price as a result of the primary adjustment). 15+ P/modifiers + amounts djusted revenue code 4 djusted P/PP 5 djusted modifier 1 2

13 djusted modifier 2 2 djusted modifier 3 2 djusted modifier 4 2 djusted modifier 5 2 djusted units 9 djusted date of service 8 Original amount per service 12 Original amount paid for the specific service djusted amount per service 12 evised amount paid for the specific service