CWF Edits on Carrier/AB MAC Claims (Rev. 2824, 04-07-14)

by  Jared Staheli
June 25th, 2015

In order to prevent duplicate payment by the same carrier/AB MAC, CWF will edit by line item on the carrier/AB MAC number, the HIC number, the date of service, the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009.

If CWF receives a claim with either HCPCS codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688 and it already has on record a claim with the same HIC number, same carrier/AB MAC number, same date of service, and any one of those HCPCS codes, the second claim submitted to CWF will reject.

If CWF receives a claim with HCPCS codes 90669, 90670, or 90732 and it already has on record a claim with the same HIC number, same carrier/AB MAC number, same date of service, and the same HCPCS code, the second claim submitted to CWF will reject when all four items match.

If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with the same HIC number, same carrier/AB MAC number, same date of service, and same procedure code, CWF will reject the second claim submitted.

CWF will return to the carrier/AB MAC a specific reject code for this edit. Carriers/AB MACs must deny the second claim and use the same messages they currently use for the denial of duplicate claims.

In order to prevent duplicate payment by the centralized billing contractor and local carrier/AB MAC, CWF will edit by line item for carrier number, same HIC number, same date of service, the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009.

If CWF receives a claim with either HCPCS codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688 and it already has on record a claim with a different carrier/AB MAC number, but same HIC number, same date of service, and any one of those same HCPCS codes, the second claim submitted to CWF will reject. If CWF receives a claim with HCPCS codes 90669, 90670, or 90732 and it already has on record a claim with the same HIC number, different carrier/AB MAC number, same date of service, and the same HCPCS code, the second claim submitted to CWF will reject.

If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with a different carrier/AB MAC number, but the same HIC number, same date of service, and same procedure code, CWF will reject the second claim submitted.

CWF will return a specific reject code for this edit. Carriers/AB MACs must deny the second claim. For the second edit, the reject code should automatically trigger the following Medicare Summary Notice (MSN) and Remittance Advice (RA) messages. MSN: 7.2 – “This is a duplicate of a claim processed by another contractor. You should receive a Medicare Summary Notice from them.”

Claim adjustment reason code 18 – duplicate claim or service

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 18