anual ystem Pub 100-20 One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 1021 Date: January 26, 2012 hange equest 7604 Transmittal 1002, dated November 23, 2011, is being rescinded and replaced by Transmittal 1021, dated January 26, 2012 to clarify the Legacy Provider/upplier D in the attached content file and to clarify the effective and implementation dates. ll other information remains the same. UBJT: utomated Tracking and eporting of ecovery udit-ssociated eopenings and ppeals. UY O NG: The currently track reopenings and appeals of adjustments initiated by ecovery uditors via monthly contractor-supplied spreadsheets; this directs implementation of the automated tracking/reporting solutions developed as a result of the conference calls held under 7469 (onference alls and esearch ours to dentify an utomated olution for Tracking and eporting ecovery uditor eopenings and ppeals throughout the edicare ppeals Process, Transmittal 944). TV DT: pril 1, 2012 and (nalysis and Design for V- July 1, 2012, coding and implementation for V) PLNTTON DT: pril 2, 2012 and (nalysis and Design for V- July 2, 2012 coding and implementation for V) 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 N/ PT / TON / UBTON / TTL n/a. 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.
ttachment One-Time Notification Pub. 100-20 Transmittal:1021 Date: January 26, 2012 hange equest: 7604 Transmittal 1002, dated November 23, 2011, is being rescinded and replaced by Transmittal 1021, dated January 26, 2012 to clarify the Legacy Provider/upplier D in the attached content file and to clarify the effective and implementation dates. ll other information remains the same. UBJT: utomated Tracking and eporting of ecovery udit-ssociated eopenings and ppeals ffective Date: pril 1, 2012 and (nalysis and Design for V- July 1, 2012, coding and implementation for V) mplementation Date: pril 2, 2012 and (nalysis and Design for V- July 2, 2012 coding and implementation for V). GNL NOTON. Background: The currently track reopenings and appeals of adjustments initiated by ecovery uditors via monthly contractor-supplied spreadsheets; this directs implementation of the automated tracking/reporting solutions developed as a result of the conference calls held under 7469 (onference alls and esearch ours to dentify an utomated olution for Tracking and eporting ecovery uditor eopenings and ppeals throughout the edicare ppeals Process, Transmittal 944). B. Policy: The nationwide ecovery udit program was mandated under Division B, Title, ection 302 of the Tax elief and ealthcare ct of 2006. 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 7604.1 ontractors shall participate in conference calls to develop requirements for tracking and reporting clerical reopening and redetermination requests for ecovery uditor-initiated adjustments within the edicare ppeals ystem (). The expansion shall initially focus on Part /Part / B D hared- ystem aintainers V W OT /ppeals /ecovery udit
Number equirement esponsibility B of, although intends to ultimately track Part B and D reopenings/redeterminations in as well. and V maintainers shall participate in calls but shall not have any deliverables for this requirement in the pril 2012 release. / B D hared- ystem aintainers V W OT ecovery uditors T anticipates weekly calls beginning in November 2011 and continuing through December 2011; the exact schedule will be communicated to stakeholders well in advance of the first call. 7604.1.1 The maintainers shall implement solutions to the requirements identified under B 7604.1. 7604.1.2 currently anticipates training contractors on the new functionality in pring 2012, with implementation in late pring or ummer 2012 (details to be provided). 7604.2, and V shall produce automated reports and flat files listing recovery audit-associated clerical reopening and appeal activity. This reporting will begin once the appeal/correspondence is flagged as a ecovery uditor appeal and the process will begin again if multiple requests are received. 7604.2.1 The reports shall be formatted for end-user viewing; the exact layout shall be at maintainer discretion but shall include the fields and code sets on the attached layout. 7604.2.2 The files shall be produced in fixed-width text format per the attached layout, using the provided code sets. 7604.2.3 The reports/files shall be produced weekly with all relevant activity in the given reporting period. Previously reported reopenings/appeals that remain in a pending status shall be listed on subsequent reports with disposition =. 7604.2.4 The BD/Ds shall send the files to the Data Warehouse via onnect:direct or other -authorized and mutually acceptable transfer protocol following already established protocols and guidelines. X /ppeals /ppeals /ppeals BD/Ds
Number equirement esponsibility 7604.2.5 f the Data Warehouse is unable to directly accept the files by the implementation date, the BD/Ds shall send the files to the appropriate contractors for upload via the Data Warehouse s online interface following already established protocols and guidelines. 7604.3 ontractors shall ensure that all Part B/D reconsideration and/or LJ activity brought to their attention is recorded in or V, as appropriate. / B D X X hared- ystem aintainers V W OT BD/Ds Whether and how will continue separately tracking reconsiderations and higher-level appeals in both /V and has not yet been determined. 7604.4 eporting shall continue until the correspondence has closed and if applicable, the adjustment has finalized. X. POVD DUTON TBL equirement esponsibility None. V. UPPOTNG NOTON / B D hared- ystem aintainers V W OT ection : or any recommendations and supporting information associated with listed requirements: N/ X-ef equirement Number ecommendations or other supporting information:
X-ef equirement Number ecommendations or other supporting information: ection B: or all other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Jennifer lmezzi (jennifer.elmezzi@cms.hhs.gov or 410-786-1023). 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 e-mail, and request formal directions regarding continued performance requirements. ttachment
ecovery udit-ssociated eopenings and ppeals (header) ield # ield Name tart nd Length Values/comments 1 ile type 1 10 10 PPL 2 iller 11 11 1 3 ile format version 12 14 3 001 4 iller 15 15 1 5 ecord count 16 21 6 Number of records in file, not including header; zero fill 6 iller 22 22 1 7 ecord length 23 28 6 000396 8 iller 29 29 1 9 ile creation date 30 37 8 YYYYDD 10 iller 38 38 1 11 ource D 39 43 5 Primary workload D of D processing region 12 iller 44 396 353 Note 1: ll fields are left justified/space filled unless otherwise indicated. Note 2: iles shall be space filled to a fixed record length.
ecovery udit-ssociated eopenings and ppeals (content) ield # ield Name tart nd Length Values/comments 1 Workload number 1 5 5 Workload number of the adjustment being appealed 2 Original claim D 6 28 23 D of the underlying claim, before adjustment by the recovery auditor (claim D selected by ecovery uditor for adjustment) 3 djustment D 29 51 23 D of the recovery audit-initiated adjustment being reopened/appealed 4 Legacy provider/supplier D 52 64 13 Billing provider D 5 eceipt date 65 72 8 YYYYDD 6 Nature of request / = lerical reopening, = edetermination 73 75 3 Level of appeal Q = Q, J = LJ, B = DB, J = Judicial review - ffirm recovery auditor decision P- Partially favorable to provider/supplier - ully favorable to provider/supplier W- equest withdrawn by provider/supplier 7 Disposition 76 78 3 D- equest dismissed by - equest for reopening accepted at the - edetermination decision pending Z- emand Notes: D is only allowable with Nature of equest = or is only allowable with Nature of equest = Z is only allowable with Nature of equest = J, B or J 8 Disposition date 79 86 8 YYYYDD (date of closure of correspondence)
ecovery udit-ssociated eopenings and ppeals (continued) ield # ield Name tart nd Length Values/comments Blank if reopening/appeal request was dismissed, ecovery uditor s 9 eadjustment D 87 109 23 decision was affirmed or decision is still pending. Otherwise, the D of the adjustment created to effectuate the reopening/appeal decision. 10 eadjustment date 110 117 8 inalization date of the readjustment 11 mount paid on readjusted claim 118 126 9 DDDDDD. (explicit decimal; padded with zeroes) - ncorrect interpretation of coding policy B- ncorrect effective date utilized for coding policy - Utilization of additional/different coding policy D- ode adjusted after 3 year limitation - edical record supplied in appeal process - Wrong policy applied eason for reversal or accepted G- Other error by ecovery uditor clerical reopening - Provider/supplier added modifier 12 127 127 1 - Provider/supplier corrected date of service (ecovery uditor error or J- Provider/supplier corrected modifier new information from K- Provider/supplier corrected diagnosis provider/supplier) L- Provider/supplier corrected procedure code - Provider/supplier corrected place of service N- Provider/supplier corrected billing number O- Provider/supplier corrected other error equired if Disposition = P, or 13 eversal narrative 128 383 256 eviewer comments; required if eason for eversal = G or O Note 1: ll fields are left justified/space filled unless otherwise indicated. Note 2: iles shall be space filled to a fixed record length. Note 3: ield 2, 3 and 9 will be the same value in V since only the last digits of the claim D are modified when an adjustment occurs. Note 4: ll information is claim level.
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 e-mail, and request formal directions regarding continued performance requirements. V. TTNT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.