CMS Pub. 100-04, ch. 27, § 20.3.5

(UR/IUR)

(Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18)

CWF system also returns unsolicited response/informational unsolicited response to

MACs when the processing of a current claim results in the need for action on a

previously paid claim. Generally, changes in a beneficiary’s entitlement or utilization

history information on Beneficiary trigger UR/IUR response. The information used to

process the earlier claim is no longer accurate and the claim must be corrected.

CWF typically sends these responses to MACs in an immediate reaction to claims the

contractor has recently submitted. An unsolicited response is an instruction from CWF to

act on a previously paid claim days or even months after the paid claim received its

original CWF response.

• Unsolicited response (UR): CWF cancels or adjusts a claim in CWF history and

sends the information in basic reply trailers (08 and 24) to the MACs to take

action.

• Informational unsolicited response (IUR): CWF system takes no action on a

claim in history, but sends basic reply trailers (08 and 24) to MACs to perform

corrective action.