Claims Processing

Claims processing systems cover the ingestion and validation of claims against rules. These systems may also generate reports to support Federal reporting requirements.

CMS-Required Outcomes (6)

Ref	Outcome	Sources
CP1 Receipt and Ingestion	The system receives, ingests, and retains claims, claims adjustments, and supporting documentation submitted both electronically and by paper in standard formats.	45 CFR 162.1102
CP2 Validation	The system performs comprehensive validation of claims and claims adjustments, including validity of services.	42 CFR 431.052 42 CFR 431.055 42 CFR 447.26 42 CFR 447.45(f)45 CFR 162.1002SMD Letter 10-017SMM Part 11 Section 11300
CP3 Prior Authorization	The system confirms authorization for services that require prior approval to manage costs or ensure patient safety, and that the services provided are consistent with the authorization. The system accepts use of the authorization by multiple sequential providers during the period as allowed by state rules. Prior-authorization records stored by the system are correctly associated with the relevant claim(s).	42 CFR 431.630 42 CFR 431.960SSA 1927(d)(5)SMM Part 4SMM Part 11 Section 11325
CP4 Calculation and Resolution	The system correctly calculates payable amounts in accordance with the State Plan and logs accounts payable amounts for payment processing. The system accepts, adjusts, or denies claim line items and amounts and captures the applicable reason codes.	42 CFR 431.052
CP5 Provide Submission Status	The state communicates claims status throughout the submission and payment processes and in response to inquiry. If there are correctable errors in a claims submission, the system suspends the claims, attaches pre-defined reason code(s) to suspended claims, and communicates those errors to the provider for correction. The system associates applicable error or reason code(s) for all statuses (e.g., rejected, suspended, denied, approved for payment, paid) and communicates those to the submitter. The system shows providers, case managers and members current submission status through one or more of the following: - Automatic notices as appropriate based on claims decision or suspension. - Explanation of Benefits (EOB). - Providing prompt response to inquiries regarding the status of any claim through a variety of appropriate technologies, and tracking and monitoring responses to the inquiries. - Application programming interface (API)	42 CFR 431.6045 CFR Part 162.1402(c)45 CFR Part 162.1403 (a) & (b)SMM Part 11 Section 11325
CP6 Record-Keeping	The system tracks each claim throughout the adjudication process (including logging edits made to the claim) and retains transaction history to support claims processing, reporting, appeals, audits, and other uses.	42 CFR 447.45 42 CFR 431.17SMM Part 11 Section 11325