CMS Part B Claims Processing

The CMS Part B Claims Processing System is a critical component of the Fee-For-Service (FFS) program, with almost $300 billion dollars in Medicare benefit outlays. The CMS Part B Claims Processing System processes more than 1 billion claims a year, supporting Medicare's mission to provide quality health care to beneficiaries. Multi Carrier System (MCS) is the shared system used to process Medicare Part B claims for physician care, durable medical equipment, and other outpatient services nationwide. MCS is over 30 years old and is considered a steady state investment. MCS interfaces directly with the Common Working File (CWF) for the purposes of providing a single data source where the contractors can verify beneficiary eligibility to receive prepayment review and approval of claims. MCS interfaces directly with the Healthcare Integrated General Ledger Accounting System (HIGLAS) to perform daily functions of payment calculation (following pre-payment validation), formatting, and accounting, thereby ensuring timely and accurate delivery of Medicare benefit payments. MCS meets CMS' core requirements for processing Medicare Part B claims, which include: data collection and validation, claims control, pricing, adjudication, correspondence, on-line inquiry, file maintenance, reimbursement, and financial processing. Claims paid through the MCS system includes value based purchases, Health Information Technology for Economic and Clinical Health (HITECH) Act as well as the new Center for Medicare and Medicaid Innovation (CMMI) initiatives; Prior Authorization, and Next Generation Accountable Care Organizations. The MCS has four quarterly releases that control, implement, and update the processing software due to legislative mandates that dictate the amount of payment for services or coverage levels, changes needed to support the Medicare Administrative Contractors (MACs) authority for the Medicare FFS Program, as well as system lifecycle sustainability change requests. Releases are a batch of software changes that consume a quarterly targeted block of hours that the maintainer uses to implement the requisite legislative mandates, MAC changes and system sustainability change requests. The releases are scheduled for implementation during the first week of January, April, July and October without schedule variance. Software changes for the claims processing operations are managed in quarterly releases developed through a change control process that begins with the Medicare Change Control Board (MCCB) review and prioritization of pending change requests. The FFS Operations Board approves the quarterly releases with oversight by the FFS Governance Council and manages/integrates day-to-day operations of the FFS program across CMS. The goal of the FFS Operations Board is to implement error-free releases that implement legislative mandates with minimal interruption to processing ensure that beneficiaries receive the correct service and providers receive the correct payment. MCS is in continual gap analysis. System/maintainer performance is reviewed on a monthly basis as a part of the Program Management Review meeting. The MCS Maintainer implements quarterly releases that reflect legislative mandates that may be meant to correct gaps in enterprise performance. The MCS Maintainer, also, implements system correction Change Requests (CRs) from CMS that are meant to tweak system sustainability.

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