CMS Pub. 100-09, ch. 6, § 30.10

MACs shall track and report telephone and written inquiry reasons using categories and subcategories

from the CMS Standardized Provider Inquiry Chart. The Documentation section of PCID contains the

latest version of the chart. MACs may add contractor-specific subcategories to track provider inquiries

within their jurisdiction (see section 30.10.D).

MACs shall apply inquiry logging, tracking and reporting across:

• All PCC call center locations (for MAC with multiple call center locations)

• All PCC triage levels (Level 1, Level 2, PRRS)

• All provider inquiries the PCC handles including general inquiries, escalated inquiries

within CSR levels, Congressional inquiries, PE, Appeals, EDI, Reopening, MR, Audits

and Reimbursement

A. Inquiry Tracking Requirements

MACs shall maintain an Inquiry Tracking System for all provider inquiries. The system shall identify at

a minimum:

1. Inquiry Type (telephone, written, walk-in).

2. Person responsible for answering the inquiry

3. Inquirer information (name, NPI and PTAN).

4. Inquiry nature (using the categories and subcategories from the CMS Standardized

Provider Inquiry Chart and contractor-specific subcategories when appropriate). This

identifies the reason or issue that caused the provider to contact the PCC.

5. Inquiry disposition, including referral to other PCSP areas or areas elsewhere at the MAC

(for example, MR, MSP) and contact information for follow-up or clarification.

6. Response timeliness

B. Inquiry Tracking Data Use

MACs shall use inquiry tracking data to enhance and improve their PCSP by:

1. Developing reports (CMS encourages MACs to review inquiry tracking data as

often as possible to prevent inquiry volume from rising, to identify patterns of

providers’ inquiries, and to monitor provider inquiry trends)

2. Identifying areas for broader provider and CSR education

3. Conducting analysis of the inquiry numbers and types to develop self-service

education

4. Assessing and monitoring Medicare and MAC internal and external policy,

process, and procedure effectiveness and efficiency

5. Documenting enhancements and innovations to improve the Medicare provider

customer service experience, operational effectiveness, and efficiency (for

example, provider self-service technology, POE website content)

6. Assessing PCC staff skill level needs based on frequency, complexity and trends

7. Identifying organizational areas or processes within the MAC’s organization that

require follow-up to maintain or reduce provider inquiries, meet response and

processing targets, meet POE targets, and reduce provider burden

C. Requirements for Classifying the Nature of Inquiries

MACs shall follow these requirements when classifying provider inquiries:

1. Use standardized categories and subcategories from the CMS Standardized

Provider Inquiry Chart to classify and log all written and telephone inquiries.

Develop contractor-specific subcategories to capture an additional detail level to

support CMS in developing new inquiry types and identifying provider education

or CSR training needs.

2. Capture the inquiry reason, not the status, disposition (for example, referrals to

the IVR), or action taken. PCC staff shall exercise best judgement to identify the

true issue behind each provider contact.

3. Track multiple issues raised by a provider during a single call or written inquiry,

provided MACs can identify the required information (See section 30.10.A) and

comply with the reporting requirements.

4. Report unclassified inquiries using the “Not Classified” field for the appropriate

category (except “General Information” which uses “Other Issues” subcategory

instead of “Not Classified”). Minimize the number of “Not Classified” and

“Other Issues” inquiries by suggesting updates to the CMS Standardized Provider

Inquiry Chart or by creating contractor-specific subcategories (See section

30.10.D).

D. Guidance for Creating Contractor-Specific Subcategories

MACs shall adhere to these requirements when creating contractor-specific subcategories:

1. Maintain a dynamic process to identify and create contractor-specific subcategories

that could lead to new or enhanced inquiry. Create contractor-specific subcategories

to continuously reduce inquiries that don’t fit existing standardized inquiry

subcategories. CMS will monitor these subcategories to assess trends and determine

future developments.

2. Avoid creating duplicate contractor-specific subcategories when the CMS Standardized

Provider Inquiry Chart provides existing standard subcategories. Don’t create

“HCPCS” under “Coding” when “Procedure Codes” already exists under “Coding.”

3. Assign descriptive names and definitions to each contractor-specific subcategory. Don’t

use generic names like “Subcategory 1” or “Contractor-Specific.” Consider using the

following when creating contractor-specific subcategories:

• MLN Matters Article numbers describing the nature of the inquiry

• RARC and CARC code combinations from CRs

• Shared Systems edits codes with definitions

• Specific claim improper payment issues (for example, coding errors,

missing medical necessity information)

• Specific claim submission errors (for example, missing documentation,

lack of signature)

4. Create contractor-specific subcategories for issues with significant operational

impact or high-volume inquiries.

5. Regularly review contractor-specific subcategories and deactivate those with low inquiry

volume (fewer than 10 inquiries for 3 consecutive months). This excludes Program

Integrity or POE specific subcategories.

6. Avoid creating contractor-specific subcategories under “Temporary Issues” that belong

in more relevant categories. Example: Create “HMO Refunds” under “Financial

Information” not “Temporary Issues.

7. Avoid provider types and specialties as contractor-specific subcategory names since

reports can filter by these categories. However, use POE training topics as contractor-specific subcategory names when appropriate.

8. Add CMS-directed contractor-specific subcategories when requested. CMS may add

contractor-specific subcategories in the PCID Contractor-Specific Subcategories

Module for immediate assessment needs.