May 2006 Newsletter

To "Q" You In

By: Quality Assurance Specialist

Medicare Part B Redeterminations

Effective for Part B redeterminations (formerly “reviews”) issued and mailed by Palmetto GBA on or after January 1, 2006, you may appeal the redetermination decision to a Qualified Independent Contractor (QIC). Palmetto no longer handles these requests. CMS issued new guidelines in Change Request #3939 and #3944 regarding this change.

All requests for reconsideration must be accompanied by any additional documentation to support the request. Listed below are the appropriate addresses to send the request, based on Date of Redetermination and State in which services were performed.

Medicare Claims Processing Systems

CMS recently published Medlearn matters article SE0605, which provides a high-level overview of the software systems Medicare uses to process claims. The purpose of this article is to provide an explanation of the Shared Systems used by CMS to process claims submitted by Medicare contractors.

Using certain systems, known within CMS as “Shared Systems,” the Medicare contractors perform traditional claims processing services and send claims to another Medicare system, known as the Common Working File (CWF) system, for verification, validation, and payment authorization. Responses are returned from the CWF concerning payments to the FI, RHHI, CMERC, or carrier, who subsequently pays for the service, if appropriate.

This article also contains a diagram that illustrates the claim processing flow, as well as an explanation of the various systems that process Medicare claims.