US · guidance
CMS Pub. 100-06, ch. 7, § 50.2
B Controls – Claims Processing
B – Control
Number
Control Objective – Claims Processing
B.1 The Medicare claims processing system tracks each claim from
receipt to final resolution.
B.2 Controls provide reasonable assurance that fee-for-service
information system edits and / or validations are configured in
accordance with CMS guidelines including:
• Management maintains a current baseline of edit
configurations in accordance with CMS guidelines.
• Management assesses the current configuration of edits
against the baseline periodically.
• For misconfigured edits Management remediates the
configuration in a timely fashion.
• Management reports results of reconciliations / reviews to
CMS periodically.
(Maintainer Only. Applicable for A-123 Reviews)
B.3 The system generates an audit trail with respect to each claim,
adjustment, or other related transaction. Such audit trail shall
include the results of each applicable claim edit.
(Maintainer Only. Applicable for A-123 Reviews)
B.4 Each claim is adjudicated in accordance with CMS instructions.
B.5 Claims are reopened in accordance with CMS guidelines and
readjudicated in accordance with CMS instructions.
B.6 Claim payment amounts are calculated in accordance with CMS
instruction. Fee schedules are properly received, logged, and
changed in the system and monitored, and applied in accordance
with CMS instructions.
B.7 The system shall identify and deny duplicate claims in accordance
with CMS instructions.
(Maintainer Only. Applicable for A-123 Reviews)
B.8 Claims are properly aged from the actual receipt date to the actual
date of payment in compliance with CMS instructions.
B.9 The system shall detect apparent fraudulent or abusive practices in
accordance with CMS instructions. Personnel are trained to detect
fraudulent and abusive practices and, in accordance with CMS
instructions, to deter such practices. Any such apparent fraudulent
or abusive practices as are identified are documented and reported
in accordance with CMS instructions.
End Section 50.2 – B Controls – Claims Processing: Back to Table of Contents
History
(Rev. 331, Issued: 11-15-19, Effective: 10-01-19, Implementation: 12-17- 19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
67abc106d6044831f8585e89cf5fc1d101e99b98884aaa7e0208bfa4125f4487
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