US · guidance
CMS Pub. 100-04, ch. 27, § 40.3
Critical Case Procedure - Establishing Entitlement
The MAC uses the "critical case" procedure (see §40.4, below) to expedite the processing
of claims which have been delayed because of an error in the beneficiary's CWF Master
Record. The "critical case" procedure provides speedy correction of the master record.
The MAC uses this procedure when there is an error in the CWF Master Record, which
prevents the receipt of an approval disposition code on the basic reply record. This may
occur when one of the following conditions exists:
• The MAC is unable to make payment on a claim even though the beneficiary
apparently has entitlement because CWF transmitted a Basic Reply Record with
an inaccurate or repeated disposition code of "50," "51," 52," "53," "54," "55,"
"57," "58," "59," "60," "61," "AB," "CI," "ER," "UR," "CR;" or
• The MAC received a Basic Reply Record and the recycled CWF Claim Records
have not received a disposition code, which permits processing the claim to
payment or denial.
History
(Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
a83a2d7101e4396258fc6cb9ad4e1335ddfedd959d1520234f2b8c560c06be4e
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