What is Other Claims (other than clean) and Data Element matrix

Claims that do not meet the definition of “clean” claims are “other” claims. “Other” claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. “Other” claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development. Examples are claims on which the provider’s FI/carrier:

• Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

• Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

• Develops Medicare Secondary Payer (MSP) information;

• Requests information necessary for a coverage determination;

• Performs sequential processing when an earlier claim is in development; and

• Performs outside development as a result of a CWF edit.

Data Element Requirements Matrix

The matrix (See Exhibit 1) specifies data elements, which are required, not required, and conditional for FI claims. The matrix does not specify item or field/record content and size. Refer the electronic billing instructions (UB-04 and ANSI 837) on the CMS Web site to build these additional edits. If a claim fails any one of these “content” or “size” edits, the FI returns the unprocessable claim to the supplier or provider of service.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers of service and suppliers. The matrix is not a comprehensive description of requirement that need to be met in order to submit a compliant transaction.