CMS Common Working File (CWF)
Investment ID: 009-000004253
Overview
Program Title
CMS Common Working File (CWF)
Description
Common Working File (CWF) is a Medicare part A and B benefit coordination and claim validation system. Common Working File (CWF) is a tool used by the Centers for Medicare & Medicaid Services (CMS) to maintain records about beneficiaries enrolled in the Medicare fee for service health plan. Used to determine the Medicare beneficiaries' eligibility for Medicare services and to monitor and inform other CMS payment systems on the appropriate usage of Medicare benefits and to ensure payments for services received are appropriately determined and applied to payments based on Medicare payment and coverage rules. Also the repository for Medicare beneficiary eligibility information that is received nightly from the Social Security Administration (SSA). The eligibility information consists of newly enrolled beneficiaries into Medicare.
Type of Program
Major IT Investments
Multi-Agency Category
Not Applicable
Investment Detail
The Common Working File (CWF) is the Medicare Part A and Part B beneficiary benefits coordination and pre-payment claims validation system which uses nine localized databases of beneficiaries called 'CWF Hosts'. Each CWF Host maintains total Medicare claim history and entitlement information for the beneficiaries in their jurisdiction as updated daily by Medicare contractors and other applicable entities. Each Medicare beneficiary is assigned to only one CWF Host site based on where the beneficiary signs up for his/her Social Security Administration (SSA) benefits. Each jurisdiction is a network of A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs), termed Satellites, and located in a defined geographic area (sector). Each MAC within the sector is linked to its CWF Host via telecommunications through their respective CMS Virtual Data Center (VDC). Each Medicare Part A, B and DME processing region creates a nightly CWF file containing claims data. The corresponding MAC's VDC transmits these files to the CWF Host. The CWF Host uses the CWF software to determine the beneficiary's eligibility and entitlement status and then uses that information to decide what action should be taken on the claim. The CWF software also checks incoming claims against all other claims types, referred to as A/B crossover, previously processed and stored in claims history to prevent duplicate payments. Prior to adjudication of claims, current claims are sent to the Fraud Prevention System (FPS), to evaluate for fraudulent activity. The claims will process through the FPS system and FPS will send back only denials, if any, to the CWF Hosts the next day. The CWF Host returns a response file back to the VDC and the file is loaded to the MACs processing region. The file will contain various disposition codes, trailers, and error codes, used by the processing systems in automatic processing during the batch cycle.Theresponses are applied to the pending claim allowing appropriate system action. Within the larger context of CMS' business, the CWF is a mission critical system now supporting over one billion claims annually and continues to grow. In following the CMS Investment Lifecycle, CWF has four scheduled (January, April, July and October) quarterly releases per year which typically include 30-40 Change Requests (CRs) along with operational problem fixes. Off-quarter releases are also delivered at the direction of CMS for Emergency, Special and Priority needs. These releases support the entire Medicare claims processing community. 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. CWF is in continual gap analysis. System/maintainer performance is reviewed on a monthly basis as a part of the Program Management Review meeting.