Implementation Delayed to Correct CWF Edit of Medicare Advantage (MA) Enrollees' Inpatient Claims from Approved Teaching Hospitals Billed for Indirect Medical Education

Current Status:
5/14/2019: CMS could not implement Change Request 10959, as planned on April 1, 2019.

Situation Identified May 6, 2019
MLN Matters Article MM10959 (PDF, 98 KB), “Update to Common Working File (CWF) Edit of Medicare Advantage (MA) Enrollees' Inpatient Claims from Approved Teaching Hospitals Billed for Indirect Medical Education” became effective April 1, 2019. CR 10959 instructs the CWF to bypass edit 5233 on claims billed with an Investigational Device Exemption (IDE) study or a clinical study approved under Coverage with Evidence Development (CED) so that the Fiscal Intermediary Shared System (FISS) can make the IME only payment on approved teaching hospital claims for MA-enrolled beneficiaries.

CMS could not implement the correction as planned on April 1, 2019. Once the correction is able to be implemented; MACs will assist hospitals in resubmitting the rejected inpatient information only claims with condition codes 04, 69, and 30, one of the approved IDE or CED study numbers listed in the most updated list MACs received from CMS and an admission date on or after April 1, 2015, through the implementation date of CR10959 upon request from the hospital. The only claims that need to be resubmitted are IME only claims that were rejected with the following reason codes.

  • U5233: Indirect Medical Education (IME) only claims for approved teaching hospitals billed with an IDE study or a clinical study approved under CED for beneficiaries enrolled in a MA plan are rejecting in error
  • 3719C: Inpatient information only claims for IDE studies and clinical studies approved under CED were processed with payment in error

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