CMS Pub. 100-04, ch. 27, § 20.1

The local CWF database for each sector resides at a Host. Each A/B and DME MAC

within the sector is linked to its Host's database. Communication between them is

electronic, with claims ready for payment or denial communicated to the Host, and

adjustments, approvals, rejects, and informational trailers returned from the Host via a

daily process. The A/B and DME MAC’s usually initiates this process. On occasion, the

CWF Host will initiate an "unsolicited response" to the A/B and DME MAC’s as a result

of a new claims action that affects a previously processed claim action.

Claims are processed by CWF in the same order that they are received, regardless of the

dates of service or receipt date. This first-in-first-out method of processing requests for

payment facilitates prompt handling of claims.

Role of CWF Hosts:

• Responsible for executing a common set of CWF software modules to maintain

Beneficiary databases by adding or updating Beneficiary entitlement information

provided by CMS

o These updates are processed by the enrollment database (EDB) and

continue to update CWF Host records as the beneficiary's entitlement

changes.

• Perform consistency; utilization, A/B cross over and duplicate edit checks to

provide authorization for MAC’s to pay claims;

• Providing and controlling linkage of the MAC’s in the sector to the Host;

Controlling and monitoring telecommunications network operations

• Supplying MAC’s with inquiry and transmission software necessary to

communicate with the Host and make full use of the CWF data inquiry features;

• Receiving, installing, testing, and operating the CWF software system, including

all changes developed by CWFM;

Role of A/B and DME Medicare Administrative Contractors (MACs):

• Submission of claims via telecommunication in batch mode to a CWF Host for

validation and payment approval;

• Receive, control, and enter claims into an automated processing system.

• Review, edit, and adjudicate claims through CWF system for determination of

eligibility, coverage, and pricing.

• Submission of online inquiries to a CWF Host to determine Beneficiary

enrollment status and eligibility

• Submit claims to the CWF Host for pre-payment validation and authorization.

• Issue payments to Providers or deny/develop claim is rejected by CWF; - Issue

Explanation of Medicare Benefits and payments to Beneficiaries.