CMS Pub. 100-04, ch. 27, § 60.2

Before a claim can be paid outside the CWF/CWF system, A/B MACs or DME MACs

shall obtain approval from their CMS COR, or his/her designee. In all instances

involving payment outside the CWF/CWF system, A/B MACs or DME MACs shall apply

the following procedures, unless otherwise specified:

• Submit the claims with an "X" in the tape-to-tape flag, and the system will

determine payment as if the payment were final. Inpatient PPS payments shall be

processed through MCE, Grouper and Pricer. Hospice payments shall be made

using the appropriate hospice rate. ESRD visits shall be paid using the composite

rate. The appropriate fee schedules or interim rates shall be used. Deductible and

coinsurance shall be applied based on the most current data available. Do not

apply the CMS-prescribed percent reduction applicable to accelerated payment.

• Follow shared system procedures to avoid sending a claim to the CWF at time of

payment, but shall also maintain a record for later submission.

• 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 duplicate

payment is not made (i.e., when the claim record is updated to CWF or in

response to a duplicate request by the provider).

• Monitor the CWF to determine when the impediment to CWF processing is

removed. Additionally, A/B MACs and DME MACs shall update the CWF when

the impediment is removed so that the actual payment date outside the CWF is

shown in the scheduled payment data field.

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

paid.