US · guidance
CMS Pub. 100-04, ch. 1, § 80.3
Other Claims (other than clean)
A3-3600.1 Item 4, HO-401.E, B2-5240.11.B
Claims that do not meet the definition of “clean” claims are “other” claims. “Other”
claims require investigation or development external to the carrier or FI’s Medicare
operation on a prepayment basis. “Other” claims are those that are not approved by CWF
for payment that the FI identifies as requiring outside development. Examples are claims
on which the provider’s FI/carrier:
• Requests additional information from the provider or another external source.
This includes routine data omitted from the bill, medical information, or
information to resolve discrepancies;
• Requests information or assistance from another contractor. This includes
requests for charge data from the carrier, or any other request for information
from the carrier;
• Develops Medicare Secondary Payer (MSP) information;
• Requests information necessary for a coverage determination;
• Performs sequential processing when an earlier claim is in development; and
• Performs outside development as a result of a CWF edit.
History
(Rev. 1, 10-01-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
d5fac1a443eca8e90a34694944e60fb18441019c0b12c64a4431be60341705ee
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