Fiscal Intermediary Standard System (FISS) Standardization Affects Certain MSP and Medicare Primary Claims

Effective - March 29, 2007

Please ensure that the information below is disseminated within your facility to all Medicare billing staff members as quickly as possible.

Before FISS Standardization

Before FISS standardization, when a provider submitted a claim to Medicare (MSP claim or Medicare primary claim) that required us to contact the Coordination of Benefits Contractor (COBC), we would “hold” the claim in our suspended claims location file “SMFECR.” We would then submit a notification to the COBC via an Electronic Correspondence Referral System (ECRS) asking them to investigate and then either terminate, create, or change an MSP file on the Common Working File (CWF). If the COBC corrected the information on the MSP file on the CWF, we would then release the provider’s claim from location SMFECR so that it could continue processing. In cases where the COBC did not update the MSP file on the CWF, we would continue to check the CWF weekly for each of the claims still remaining in the SMFECR location. However, if the COBC had not taken the requested action on the MSP file on the CWF within 100 days of our initial ECRS notice, we would return the claim to the provider (RTP) with reason code 74050 so that the provider could monitor the CWF directly for the COBC’s update to the CWF and/or contact the COBC directly to check on the status.

After FISS Standardization

With the standardization of FISS, the process described above has changed. We will continue to contact the COBC via an ECRS notice when we receive a claim that requires us to do so. But, we will then RTP the claim with reason code 75003 for the provider to monitor the MSP file on CWF to see that the COBC makes the necessary correction(s). We will no longer hold the claim in our suspended claims file SMFECR and no longer monitor for the COBC’s correction(s). This is now the provider’s responsibility. Once the provider identifies that the COBC completes their correction(s) to the MSP information on CWF, they can resubmit their RTP claim.

Effective March 29, 2007, we will be checking all of the current pending claims in our “SMFECR” location. If the COBC has not made the necessary correction(s) to the MSP information on CWF, we will RTP the claims with reason code 75003 immediately (see description below).

It is important for the provider to remember not to resubmit the RTP claim or submit a new claim until the respective MSP file on CWF has been updated by the COBC. If we receive this type of resubmitted claim, we will RTP it with reason code 75004 (see description below).

Reason code 75003 (COBC has been contacted, provider must monitor CWF for update)

As of December 2000 - all Medicare secondary payer claims investigations are to be initiated from, and researched by the COB contractor. The COBC uses a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance coverage primary to Medicare. They are the sole authority in ensuring the accuracy and integrity of the MSP information contained at CWF. We have forwarded the record information from this claim to the COBC, please wait for their file update before re-submitting this claim. We cannot process without an applicable file at CWF. You may wait and resubmit after the correction or contact them directly at the toll-free number - 1-800-999-1118- to get a status.

Reason code 75004 (RTP or new claim resubmitted before CWF update):

As of December 2000 - all Medicare secondary payer claims investigations are to be initiated from, and researched by the COB contractor. The COBC uses a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance coverage primary to Medicare. They are the sole authority in ensuring the accuracy and integrity of the MSP information contained at CWF. We had forwarded the record information prior from this claim to the COBC, asking you to please wait for their file update before re-submitting. We cannot process without an applicable file at CWF. We asked that you wait and resubmit after the file changes took place or contact them directly at the toll-free number- 1-800-999-1118- to get a status. You have re-submitted this claim without the files being changed at CWF. This claim cannot be processed without the file changes.