CMS Pub. 100-04, ch. 3, § 20.2.1.1.2

MCE

(Rev. 2117, Issued: 12-10-10, Effective: 01-12-11, Implementation: 01-12-11)

Before an inpatient claim may be paid without first going through the MCE, the contractor

shall obtain approval from CMS Central Office or the RO.

Note: In certain situations, contractors bypass the MCE through an established, CMS-

instructed claim processing procedure (e.g., to verify a facility is certified to perform a

specified service after a MCE limited coverage edit is applied). Such scenarios do not

require approval from the RO as the approval for such a bypass was inherently implied when

the established procedure was first implemented.

In all instances involving payment outside the normal inpatient editing process, the

contractor applies the following procedures:

• Contractors shall submit the claim overriding the MCE using the appropriate field in

FISS.

• Pay interest accrued through the date payment is made on clean claims. Do not pay

any additional interest.

• Maintain a record of payment and implement controls to be sure that incorrect

payment is not made, i.e., when the claim is paid without being subject to normal

editing.

• Monitor MCE software to determine when the impediment to processing is removed.

• Consider the claim processed for workload and expenditure reports when it is paid.

• Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month

a report of all inpatient claims paid without processing through the MCE with the

exception of override situations explained in the Note above (e.g., for limited

coverage edits). The list of claims paid outside of the MCE is to include the

following information:

o HIC

o DCN

o TOB

o DOS (From/Through)

o Provider Number

o MCE/OCE OVR (Claim/Line)

o Reimbursement Amount

o Receipt Date

o Process Date

o Paid Date

Also, include summary data for each edit code showing claim volume and payment. Any

override approvals received and/or relevant JSM references should be annotated on the

reports.