524 Report

Background
The Centers for Medicare and Medicaid Services (CMS) occasionally will pay for a beneficiary’s
medical services more than once. When the Common Working File (CWF) receives notification
that a beneficiary has previously enrolled in a Managed Care Plan and the enrollment has posted,
the CWF file will search claims history to determine whether any fee for service claims were
erroneously approved for payment during the Managed Care enrollment period. Once the CWF
recognizes a payment has been made for a beneficiary enrolled in a Managed Care Plan, a
response will be sent to the Fiscal Intermediary (FI) for the recovery/recoupment of overpayment
on claims during the Medicare Advantage (MA) Plan enrollment period.

Actions

Claims Examiner
I. Review Report 524 on a daily basis for the comments on the disposition listed and take action
as defined below:
A. ADJUSTMENT CLAIM CREATED - FISS automatically created an unsolicited response.
• Claims Examiner should verify via the Claim Summary screen that the claim is residing in
ST/LOC B9997; Claims Examiner should scroll down the column as it appears on the 524 Report.
Once the claim is verified no further action is needed.
• Claims Examiner should verify original claim is residing B9996; Claims Examiner should scroll
down the column as it appears on the 524 Report. Claims Examiner should verify the
Beneficiary’s file on CWF indicates an HMO episode for the dates of service. On CWF, select
BENA file, enter the HIC as listed on the report. Then, select the beneficiary’s GHOD file, verify
HMO benefits and validate dates of service are within the HMO period. Once the dates of service
on the report is verified in the beneficiary’s GHOD/HMO period, access the beneficiary’s Hospice
(HOSP) period. Verify original claim is in B9996 and adjusted claim is suspending to ST/LOC
MCWFR receiving reason code 30916. Claims Examiner must monitor suspended claims. To do
this, claims examiner must expand dates of service on the Claim Summary screen, review
original and adjusted claim. Once original claim has a date in the PAID DATE field on Claim
Summary screen and the current date is one day later than the paid date, the Claim Examiner
should verify that the original claim has been moved to ST/LOC PB9997. Once, the original claim
is in PB9997, the Claims Examiner should access the suspended adjustment (DCN ends in ‘U’ -
type of bill will be XXG) and F9 to continue processing the adjusted claim. If the adjustment claim
is processed in error, the Claims Examiner should contact the Part A Departmental Operations
Analyst for additional research.
B. HISTORY CLAIM WAS CANCELED - No action is required. FISS has adjusted or canceled
the original claim identified.
C. HIST-CLAIM OFF-LINE, CREQ CREATED - No action is required. FISS will request the
retrieval of the off-line claim on the next Friday night batch cycle.
D. HIST-CLAIM OFF-LINE, CREQ WAITING - No action is required. FISS will automatically
create an unsolicited response.
E. ADJUSTMENT CREATED CLAIM NOT FOUND - Action is required to identify the corrected
HIC and batch a hardcopy claim, if appropriate:
• On CWF, select BENA file, enter the HICN as listed on the report. The BENA file will reflect the
corrected HICN in the CORR field directly below the HICN entered.
1. On FISS, enter the corrected HICN to pull all claims history. If the report does not reflect the
date of service (DOS), the claim in question will need to be identified by DCN. Review the claim
summary history by paging through (F6) until the claim with the appropriate DCN is identified.
2. Pull up the corrected HICN and DOS and review for the following:
a. If a CAN DATE is present on the claim summary page, ensure the adjustment or cancel is
viewable. It may require the DOS be spanned to identify the adjustment and/or cancel.
I. If the original claim has a CAN DATE and the adjustment or cancel has finalized after the
Report 524 date, no action is required.
II. If unable to locate the adjustment/cancel or it finalized before the Report 524 date, forward the
HICN, DOS, DCN and Response to Part A Claims Supervisor or Part A Part A Departmental
Operations Analyst for additional research.
b. If no CAN DATE is present on the claim summary page, print a copy of page 01 for an
unsolicited response adjustment to be batched based on the finalization date as defined in the
following criteria:
I. The claim must be finalized in location P/B9997, before the unsolicited response adjustment
can be batched.
II. If the claim is pending in location P/B9996, page 01 for the adjustment must be held for
batching on the next business date following the PD DATE as seen on the claim summary.
III. If the claim has finalized in a R/B9997 or D/B9997, then forward HIC, DOS, DCN and
Response to Part A Claims Supervisor or Part A Part A Departmental Operations Analyst for
additional research.
F. HISTORY CLAIM STATUS IS NOT PAID - FISS did not create an adjustment. Claims
Examiner should verify that the original claim was Rejected or Denied. Once the original claim is
verified, no further action is needed. If original claim did not reject or deny, the Claims Examiner
should contact the Part A Departmental Operations Analyst for additional research.
NOTE: The 524 report will generate on average a total of 9 to 20 claims per report (daily reports
total count can receive more or less). This report will generate on average 100 claims toward the
end of the month. If the Claims Examiner has concerns with a spike in the number of claims
adjusted, contact the Part A Departmental Operations Analyst for additional research.
Claim Operations
I. Research any problems/issues that cannot be resolved by Claims Examiner or Part A
Departmental Operations Analyst and/or response(s) that are not defined in above, and provide
clarification and/or revisions to work instructions, as appropriate.
All contents ©2009 First Coast Service Options, Inc.