CMS Pub. 100-04, ch. 27, § 60.1

A/B MACs or DME MACs may also request approval from CMS in specific situations to

pay claims without CWF approval. Examples of such situations are:

• Other A/B MACs or DME MACs cannot complete action to remove an

impediment that blocks a contractor from processing of a claim; and/or

• A systems error cannot be corrected timely, and the provider's cash flow will be

seriously endangered.

• Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions

in particular cases may necessitate that payment be made outside the normal CWF

process.

A/B MACs or DME MACs shall obtain approval from CMS to pay a claim without CWF

approval prior to processing that claim outside the CWF/CWF system. A/B MACs and

DME MACs shall submit a written request to their CMS Contracting Officer

Representative (COR) for approval to make payment without CWF approval. Such

requests shall be submitted by facsimile transmission or via the Internet. To ensure the

protection of the Personal Health Information (PHI) and Personally Identifiable

Information (PII) contained in contractor requests to pay claims without CWF approval,

contractors shall encrypt their E-mail submitted requests.

A/B MACs or DME MACs shall provide the following information to their CMS COR

when requesting to pay a claim without CWF approval:

a) A/B MAC or DME MAC’s Internal Claim Control Number,

b) Medicare beneficiary identifier,

c) Beneficiary Name,

d) Provider Number (National Provider Identification (NPI) Number),

e) From and To Date of Service,

f) Procedure Code(s),

g) Total Charges,

h) Amount to be Paid,

i) CWF Error Code/Condition Preventing Payment (including error code definition),

and

j) Rationale for Paying the Claim Outside the CWF/CWF System.