CMS Pub. 100-05, ch. 6, § 40.5

A/B MACs and DME MACs shall follow the instructions cited in Pub. 100-05, Chapter 5

for counting savings on MSP cost avoided claims.

They shall submit ALL MSP cost avoided claims to CWF.

Payment/Denial codes are used to identify the reason a claim was denied. Specific codes

for MSP are listed and defined in §10.2 under the MSP/ Contractor Number chart in

that section. A/B MACs (Part B) and DME MACs submit the appropriate code to CWF

in the Health Utilization Part B Claim ("HUBC") claim record in field 63

"Payment/Denial Code" for line item denials. They complete the appropriate code for

full claim denials in the "HUBC" claim record, field 16 "Payment/Denial". A/B MACs

(Part A) submit the appropriate code in the Health Utilization Inpatient Claim (HUIP)

CWF record field 58 "Nonpayment" code for inpatient hospital and SNF claim denials.

They submit the appropriate code in field 59 "No Pay Code" of the CWF record for the

specific type of claim identified in the chart below.

PAYMENT/DENIAL CODE FIELDS IN CWF CLAIM RECORD

Contractor Type of Claim CWF

Record

Field

A/B MAC (Part B)

and DME MAC

Full Claim Denial HUBC 16 Payment/Denial

A/B MAC (Part B)

and DME MAC

Full Line Item

Denial

HUBC 63 Payment/Denial Code

A/B MAC (Part A)

and DME MAC

Inpatient hospital

and inpatient SNF

Denial

HUIP 58 Nonpayment Code

A/B MAC (Part A)

and DME MAC

Health Utilization

Outpatient (HUOP)

HUOP 59 No Pay Code

A/B MAC (HH&H) Health Utilization

Home Health

(HUHH)

HUHH 59 No Pay Code

A/B MAC (HH&H) Health Utilization

Hospice Claim

(HUHC)

HUHC 59 No Pay Code

If a denial indicator is incorrect, the CWF software will correct the denial indicator based

on the matching MSP auxiliary record and send the correct value back to the contractor

on the response record header. It is not necessary for an MSP auxiliary record to be

present in order to post MSP cost avoided savings. If one is present, the A/B MAC or

DME MAC uses the "X" or "Y" override code as appropriate.