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Pub 100-20 One-Time Notification Centers for Medicare & Medicaid Services (CMS) Transmittal: 863 Date: February 18, 2011 Change Request 7215

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Pub 100-20 One-Time Notification Centers for Medicare & Medicaid Services (CMS) Transmittal: 863 Date: February 18, 2011 Change Request 7215 Department of Health & CMS Manual System Human Services (DHHS) Pub 100-20 One-Time Notification Centers for Medicare & Medicaid Services (CMS) Transmittal: 863 Date: February 18, 2011 Change Request 7215 NOTE: Transmittal 810, dated November 12, 2010 is being rescinded and replaced by Transmittal 863, dated February 18, 2011 CMS has changed the Effective Date to April 1, 2011 and the Implementation Date to April 4, 2011 for all Shared Systems. SUBJECT: “Integrated Data Repository (IDR) Claims Sourcing from Shared System Implementation” Based on Further Conference Calls and Further Research I. SUMMARY OF CHANGES: The CMS has determined that it will use the Shared Systems claims data for fraud, waste and abuse detection. EFFECTIVE DATE: April 1, 2011 IMPLEMENTATION DATE: April 4, 2011 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE N/A III. FUNDING: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets. For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: One-Time Notification *Unless otherwise specified, the effective date is the date of service. Attachment – One-Time Notification Pub. 100-20 Transmittal: 863 Date: February 18, 2011 Change Request: 7215 NOTE: Transmittal 810, dated November 12, 2010 is being rescinded and replaced by Transmittal 863, dated February 18, 2011. CMS has changed the Effective Date to April 1, 2011 and the Implementation Date to April 4, 2011 for all Shared Systems. SUBJECT: “Integrated Data Repository (IDR) Claims Sourcing from Shared Systems – Implementation” Based on Further Conference Calls and Further Research EFFECTIVE DATE: APRIL 1, 2011 IMPLEMENTATION DATE: APRIL 4, 2011 I. GENERAL INFORMATION A. Background: The shared systems IDR (SSIDR) will receive feeds from the three shared systems – the FISS, MCS and VMS. Specifically, the Enterprise data centers (EDCs) will send files for each shared system that are based on the copybooks the shared systems maintainers continuously provide to the Centers for Medicare & Medicaid Services (CMS). Once files are received, CMS requires the SSIDR to perform a file consistency validation on each file the shared systems send prior to accepting and retaining the files at the Baltimore data center (BDC). To accomplish these requirements, the CMS requires changes to the shared systems files and submission processes. B. Policy: The CMS has determined that it will use the shared systems claims data for fraud, waste and abuse detection. II. BUSINESS REQUIREMENTS TABLE Number Requirement Responsibility (place an “X” in each applicable column) A D F C R Shared-System OTHER / M I A H Maintainers B E R H F M V C R I I C M W M M I S S S F A A E S C C R 7215.1 The shared systems maintainers and the Enterprise data X X X EDCs centers (EDCs) shall work with CMS to finalize a communications plan. 7215.1.1 The communications plan shall address how CMS and X X X EDCs the EDCs shall exchange information on the status of and BDC EDC submissions to the BDC. 7215.1.2 The communications plan shall address how CMS and X X X EDCs the EDCs shall share information on the process for EDC and BDC submissions of shared systems data to the BDC. 7215.1.3 The communications plan shall follow all current and X X X EDCs future IDR conventions that CMS specifies. and BDC 7215.1.4 The communications plan shall be updated quarterly to X X X EDCs reflect changes in: 1) IDR conventions, 2) CMS and BDC Number Requirement Responsibility (place an “X” in each applicable column) A D F C R Shared-System OTHER / M I A H Maintainers B E R H F M V C R I I C M W M M I S S S F A A E S C C R infrastructure, and 3) data center processes. 7215.1.5 The communications plan shall include a plan for regular X X X CMS conference calls that occur at least every other week and and continue at least until the shared IDR systems modules EDCs for the shared systems are implemented at the EDC. 7215.1.6 All parties shall participate in regular conference calls as X X X X X X X X CMS defined by the communications plan. and EDCs 7215.2 Contractors shall supply a crosswalk between old IDs or X X X X X X X EDCs values and new IDs or values where the ID or value changes because of a change in the contractor organization (such as transition to a MAC) or a change in CMS or MAC policies. 7215.2.1 The crosswalk shall include changes for the following X X X X EDCs IDs or values: • Reason codes; • Action codes; • Status codes; • Location codes; • Assignment codes; and • MAC-specific codes. The FISS maintainer has indicated that they do not maintain crosswalks; therefore, this requirement does not apply to FISS. If at a later date, the FISS maintainer finds that the values do change, they will supply the appropriate cross walks. The MCS maintainer has indicated that they do not maintain crosswalks; therefore, this requirement does not apply to MCS. If at a later date, the MCS maintainer finds that the values do change, they will supply the appropriate cross walks. The VMS and DME MACs have indicated that the values in their database are not reused and that the VMS history file is not changed; therefore, this requirement does not apply to VMS or DME MACs. If at a later date, the DME MACS or the VMS maintainer finds that the values do change, they will supply the appropriate cross walks. 7215.2.2 The crosswalks shall be submitted in time for the daily X X X X X EDCs updates using the new codes to begin on the implementation date of the changes. Number Requirement Responsibility (place an “X” in each applicable column) A D F C R Shared-System OTHER / M I A H Maintainers B E R H F M V C R I I C M W M M I S S S F A A E S C C R 7215.2.3 Shared systems maintainers, contractors, EDCs, and X X X X X EDCs CMS shall finalize plans for delivery of crosswalks as part of the conference calls identified for requirement 7215.1.5. 7215.3 The CMS shall issue a subsequent CR to require X X EDCs submission of certificates of medical necessity (CMNs) and for Phase 3 claims included in the history files. CMS 7215.4 Shared systems maintainers, contractors, EDCs, and X X X X X X X X EDCs CMS shall finalize plans for delivery of history files as and part of the conference calls identified for requirement CMS 7215.1.5. 7215.4.1 The FISS shall deliver history data. X 7215.5 Shared system maintainers, contractors, EDCs, and CMS X X X X X X X X EDCs shall finalize plans for delivery of daily files as part of and the conference calls identified for requirement 7215.1.5. CMS 7215.6 The EDCs shall include the following types of claims in EDCs their transition file, i.e., claims in process on the day the EDC creates the history files that are submitted to CMS: • Claims that are enumerated, accepted into the shared systems, and in-process • Claims that are in a finalized status. 7215.7 The EDCs and CMS shall conduct a pilot test of history EDCs and daily file transmissions using a sample of workloads and that CMS and the EDCs agree upon as part of the CMS conference calls identified for requirement 7215.1.5. 7215.8 The EDCs shall provide the job control language to EDCs transmit history and daily files for each workload for and which the EDC is responsible. CMS 7215.8.1 The EDCs shall make updates to the JCL code as CMS EDCs directs. and CMS 7215.9 The EDCs shall be responsible for all aspects of the EDCs transmission of files to the BDC. and CMS 7215.9.1 The EDCs shall be responsible for correcting EDCs transmission errors such as duplicate transmissions and and CMS interrupted transmissions. 7215.9.2 The EDCs shall be responsible for documenting any EDCs changes in the shared systems modules needed to correct and CMS transmission problems. 7215.9.3 The EDCs shall be responsible for obtaining and EDCs installing changed code where changes in the shared and systems modules are needed to correct transmission CMS problems.
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