CMS Pub. 100-06, ch. 6, § 130.2

This part of the report presents data on carrier claims processing activity during the reporting

period. Counts of claims (real and replicate) processed, total claims (real and replicate) pending,

or pending from prior months must reflect the actual status of claims (real or replicate) workloads

as of the last day of the reporting calendar month. Data shown must be based on reliable counts of

all claims (real or replicate) processing activity and the entire "in-house" pending workload. This

data may not be derived from estimates.

If a single claim is split into two or more real claims, or into one real claim and one or more

replicate claims, the carrier considers each split (real and replicate) as a separate, distinct claim for

purposes of counting claims. The original real claim is a receipt for the month in which it was

received. It counts a claim split from the original, or identified as a replicate, as a receipt for the

month in which it is actually created or in which its system recognizes it as a separate claim. To

determine the age of pending claims, the carrier considers the receipt date as the date the original

claim was received and not the date it was split from another claim.

It reports, in Part A, only data relating to initial claims (real and replicate) actions. It does not

report data on requests for, or dispositions of, reviews, hearings, or reopenings of initial claim

actions.

Opening Pending

Line 1. Claims Pending End of Last Month - The system will pre-fill the number

pending from line 17 on the previous month's report.

Line 2. Adjustments - If it is necessary to revise the pending figure for the close of

the previous month, the carrier reports the adjustment, preceded by a minus

sign for negative adjustments, as appropriate. Adjustments normally result

from:

• Private claims incorrectly counted as Medicare claims;

• Beneficiary inquiries or other correspondence incorrectly counted

as Medicare claims; and

• Claims consisting of one or more continuation forms incorrectly

counted as more than one Medicare claim.

The carrier reports claims received near the end of the reporting month, and

placed under computer control sometime after the reporting month, as

claims received in the reporting month. It does not count them as claims

received in the following month. If some claims have not been counted in

the proper month's receipts, it counts them as adjustments to the opening

pending in the subsequent month.

Line 3. Adjusted Opening Pending - The system will sum line 1 + line 2 to

calculate the adjusted opening pending.

Receipts

Line 4. Total Claims Received During Month - The carrier reports all real claims

received during the month and all split and replicate claims generated

(recognized) during the month. (See the Medicare Claims Processing

Manual for a discussion of what constitutes a claim.) Claims received

include all claims received in its mailroom during the reporting month even

though some of them were placed under computer control in the following

month. (See §120.1 for counting receipts.)

The carrier counts claims submitted electronically after they have passed its

consistency edits. Prior to that time, it may return these bills or the entire

tape (where magnetic tape is the medium of submission), as necessary,

without counting them as received. However, once the claims or tapes

have passed consistency edits and are counted as received, it uses the actual

receipt date, not the date the edits are passed, in calculating pending and

processing times.

Line 5. Transferred to Other Carriers - The carrier reports the number of claims

received, but transferred to other carriers or Part A intermediaries, during

the month because the claimant submitted the claim to the wrong

contractor. It includes claims transferred in their entirety or split off from

other claims because they contained services from physicians/suppliers

outside of their carrier jurisdiction.

Line 6. Net Number of Claims Received - The carrier shows the net number of

claims (real and replicate) received after subtracting those transferred.

Line 7. Electronic Media Claims Received - The carrier reports the net number of

claims included in line 6 which were received in paperless form via

electronic media from providers or their billing agencies and read directly

into its claims processing system. It does not count on this line claims that

it received in hardcopy and entered using an Optical Character Recognition

(OCR) device. It does not count any claims received in hardcopy and

transformed into electronic media by any entity working for it directly or

under subcontract.

It counts claims which are split automatically by computer, without manual

intervention, as electronic media claims. This includes "required" splits

only. (See the Medicare Claims Processing Manual. It excludes replicate

claims).

Claims Processed

Line 8. Total CWF Claims - The carrier reports the number of initial claims

(described in lines 9, 10 and 11 below) processed through Common

Working File (CWF) and posted to CWF history. It does not include

claims sent to CWF and rejected, unless they were resubmitted and posted

to CWF history in the reporting month. The counts entered in lines 9, 10

and 11 are exclusive of each other and represent the total number of CWF

claims (real or replicate) processed during the month. On page 1, it reports

these claims in the month it move the claim to a processed location in its

system after receipt of the host's response to pay, apply entirely toward the

deductible or deny in full. For pages 2-9, it reports these claims as

processed in the month during which the scheduled payment date falls,

which may be in a subsequent reporting period.

Line 9. Claims Paid - The carrier reports the number of initial CWF claims (real or

replicate) that it approved for payment and for which the CWF host

responded by accepting its determination during the month. It reports only

claims which are completely processed. If payment is made on part of a

claim and the remainder of the claim requires no payment or is denied for

any reason, it reports the claim as paid. It reports claims that have been

fully adjudicated, with a response having been received from the CWF

host, and that are being held only due to the payment floor.

Line 10. Claims Applied Towards Deductible - The carrier reports the number of

CWF claims (real or replicate) for which no payment was made because the

deductible had not been met. It includes claims for which all charges were

applied toward the deductible, as well as those for which some charges

were denied.

Line 11 Claims Denied - The carrier reports the number of CWF claims (real or

replicate) for which all services were denied because, for example, the

beneficiary was not eligible for Part B benefits, the filing limitation was

exceeded, or services were not covered.

Line 12. Total Non-CWF Claims - The carrier reports the number of initial claims

(real or replicate) processed outside CWF. Non-CWF claims are those

either rejected by or not submitted to CWF which it finally adjudicates

outside of CWF and are, therefore, not posted to its history in the reporting

month. It reports these claims as non-CWF, even if it plans to submit an

informational record in the future. Also, it reports these claims in the month

in which it made the determination as to their final disposition.

Line 13. Claims Approved - Of those claims reported on line 12 as not processed

through CWF, the carrier reports the number approved for payment or with

all charges applied toward the deductible.

Line 14. Claims Denied - Of those claims reported on line 12, the carrier reports the

number on which all services were denied.

Line 15. Total Claims Processed - The carrier reports the sum of lines 8 and 12.

Line 16. Replicate Claims Processed - The carrier reports the number of replicate

claims included under Total Claims Processed, line 15, column (1).

Replicate claims are those claims split off from original (real) claim.

Replicate claims are generally created because of computer line item

limitations, the carrier is making partial payments, or it is carving out

individual specialty types of services. (See the Medicare Claims

Processing Manual, Publication 100-04, Chapter 1, Section 70.2.).

Closing Pending

Line 17. Claims Pending at End of Month - The system calculates the number of

bills pending at the end of the month by adding line 3 (adjusted opening

pending) to line 6 (net receipts) and subtracting line 15 (total processed). It

does not report as pending those bills that the carrier has moved to a

processed location after being accepted by the host and are holding only

due to the payment floor. It reports such bills as processed on line 17.

Distribution by Days Elapsed Since Receipt

Line 18. 1-15 Days - The carrier reports the number of claims, by type, included in

line 17 which are 1-15 days old.

Line 19. 16-30 Days - The carrier reports the number of claims, by type, included in

line 17 which are 16-30 days old.

Line 20. 31-60 Days - The carrier reports the number of claims, by type, included in

line 17 which are 31-60 days old.

Line 21. 61-90 Days - The carrier reports the number of claims, by type, included in

line 17 which are 61-90 days old.

Line 22. Over 90 Days - The carrier reports the number of claims, by type, included

in line 17 which are over 90 days old.

Claim Investigations

Line 23. Number of Claims Investigated During Month - The carrier reports the

number of claims (real and replicate) that required contact during the

month by telephone, correspondence, or automatic inquiry with physician,

beneficiary, supplier, or social security office, or other entities outside the

carrier for missing, incorrect, or inconsistent information. It counts only

the number of claims investigated, not the number of contacts made.