Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 971 Date: October 26, 2011

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1 anual ystem Pub One-Time Notification epartment of Health & Human ervices (HH) enters for edicare & edicaid ervices () Transmittal 971 ate: October 26, 2011 hange equest 7519 UBJET: nstructions for the iscal ntermediary hared ystem () to modify the Workers ompensation et side (W) laims Process to apture the mount edicare would have paid when the laim is returned by W. This change request also updates the P avings eport to add pecial Project avings Total on the avings eport to include totals from all pecial Projects.. UY O HNGE: instructs to modify the W claims process to capture the amount edicare would have paid when the claim is returned by W as W. is also modifying the P avings report to add a pecial Project avings Total on the avings eport to include totals from all pecial Projects. EETVE TE: pril 1, 2012 PLEENTTON TE: pril 2, 2012 isclaimer 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. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. HNGE N NUL NTUTON: (N/ if manual is not updated) =EVE, N=NEW, =ELETE-Only One Per ow. /N/ HPTE / ETON / UBETON / TTLE N/. UNNG: or iscal ntermediaries (s), egional Home Health ntermediaries (HHs) 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. TTHENT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

3 ttachment One-Time Notification Pub Transmittal: 971 ate: October 26, 2011 hange equest: 7519 UBJET: nstructions for the iscal ntermediary hared ystem () to modify the Workers ompensation et side (W) laims Process to apture the mount edicare would have paid when the laim is returned by W. This change request also updates the edicare econdary Payer (P) avings eport to add pecial Project avings Total in the P avings eport to include totals from all pecial Projects. Effective ate: pril 1, 2012 mplementation ate: pril 2, GENEL NOTON. Background: hange equest 5371 was released in 2009 which outlined claims processing rules for the W arrangements. The hange equest stated that pursuant to 42 U y(b)(2) and 1862(b)(2)()(ii) of the ocial ecurity ct, edicare is precluded from making payment when payment has been made or can reasonably be expected to be made under a workers compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance. onsequently, edicare should not make payment for future medical expenses associated with a settlement, judgment or award because payments has been made for such items or services. determination regarding a proposed W amount is a determination regarding the amount of future medicals associated with a particular W settlement, judgment or award and is to be used in making claims payment determinations once there has been a settlement, judgment or award. The edicare ontractors shall pay primary on claims or services that are not related to the diagnosis codes on W uxiliary records with an P code W, assuming that no other P record exists on W. must also capture the P savings for the W special project 7019 when such claims are received and edicare makes a zero payment. This instructs to modify the W claims process to capture the amount edicare would have paid when the claim is returned by W as W. This is also modifying the P avings report to add a pecial Project avings Total in the P avings eport to include totals from all pecial Projects except for VE. VE totals will continue to be reported in the VE special project. B. Policy: The standard system shall modify the W claims process to capture the amount edicare would have paid when the claim is returned by W as W, prior to assigning to reject the claim for pecial Project 7019 of the P avings eport. This modification shall allow savings to be correctly displayed on the 09 and 09Z P avings etail eports.. BUNE EQUEENT TBLE Number equirement esponsibility (place an X in each applicable column) / hared- ystem OTHE B E aintainers E H H

4 The standard system shall modify the W claims process to capture the amount edicare would have paid when the claim is returned by W as W, prior to assigning to reject the claim for pecial Project 7019 of the P avings eport shall ensure that the savings captured in the form of the amount edicare would paid are correctly displayed on the 09 and 09Z P avings etail eports and shall implement a P pecial Project avings Total on the P avings eport to include totals from all pecial Projects except for VE and TOT ll Part ontractors shall total each respective P pecial Project avings, except for VE and TOT, and place these totals in the P pecial Project avings Total in the OW P avings eport OW, ontractors and hared ystems shall continue to identify the VE totals in the VE special project OW, and Part contractors shall review and implement the format found in the attachment as described in and X X V W X OW X X X X OW OW X X X X OW. POVE EUTON TBLE Number equirement esponsibility (place an X in each applicable column) / hared- ystem OTHE B E aintainers None. E H H V W. UPPOTNG NOTON ection : or any recommendations and supporting information associated with listed requirements, use the box below: N/ X-ef equirement Number ecommendations or other supporting information: ection B: or all other recommendations and supporting information, use this space: N/

5 V. ONTT Pre-mplementation ontact(s): ichard azur, (410) Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNNG ection : or iscal ntermediaries (s), egional Home Health ntermediaries (HHs), and/or arriers, use only one of the following statements: 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), include the following statement: 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.

6 NTONL TOTL PEL POJET VNG TOTL EPTON LNE NUBE TOTL WOKE' OP (including BL) (codes 15 & 41) WOKNG GE (code 12) E (code 13) UTO EL / NO ULT BLE (code14) (code 43) Liability (including T) (code 47) V/OTHE EEL (codes 42 & 16) Prepay avings: ost void (# of claims) ost void ($) ull ecovery (# of claims) ull ecovery ($) Partial ecovery (# of claims) Partial ecovery ($) Total Prepay avings(# of claims): Total Prepay avings($):

7 Postpay avings: ull ecovery (# of claims) ull ecovery ($) Partial ecovery (# of claims) Partial ecovery ($) Total Postpay avings(# of claims): Total Postpay avings($): Total ost void avings(# of claims) Total ost void avings ($) Total ull ecovery avings(# of claims) Total ull ecovery avings($) Total Partial ecovery avings(# of claims) Total Partial ecovery avings($) Total avings (# of claims): Total avings ($):

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1003 Date: November 25, 2011

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1003 Date: November 25, 2011 anual ystem Pub 100-20 One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 1003 Date: November 25, 2011 hange equest 7489 Transmittal 942, dated