Cortex EDI

Medicare DME Real-Time Claim Status Inquiry (including "Same or Similar")
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Real-Time Claims Status Inquiry (CSI) allows you to electronically check the status of production claims after they have passed the front-end edits and received Claim Control Numbers (CCN).  Through CSI, you will know if your claim has been paid, denied, or pending.  At least three working days after you successfully file a claim, you will be able to locate your claim in the processing cycle.  Payment information is available for both electronic and paper claims. Also through CSI, you are able to receive payable Certificates of Medical Necessity (CMN) Information - this function will tell you if your patient has been issued the "Same or Similar" equipment by another provider.

What information can you get from CSI?

• CSI is divided into three main functions.  These functions are:
  • CMN Status Information (including "Same or Similar")
  • Claims History Information
  • Pending Claims Information

CMN Status Information (including "Same or Similar") - View Sample Response

• This function allows users to view payable Certificates of Medical Necessity (CMNs) for specific beneficiaries, for specific Healthcare Common Procedure Coding System (HCPCS) codes. This will provide the following information when a same or similar HCPCS code is found in the common working file or the DME Jurisdiction's local records:
  • HCPCS code and modifier
  • Initial date on file
  • Recertification date (if applicable)
  • Last day the item was billed
  • Supplier name
  • Supplier phone number
  
  
• This option will search the local processing system and provide status on these types of items:
  • Oxygen
  • Pneumatic compression devices
  • Osteogenesis stimulators
  • Transcutaneous electrical nerve stimulators (TENS)
  • Seat lift mechanisms
  • Enteral/parenteral nutrition
  • External infusion pumps
  • Respiratory items (positive airway pressure devices, nebulizers, respiratory assist devices)
  • Hospital beds
  • Mobility devices (canes, crutches, walkers, manual wheelchairs, power wheelchairs, power operated vehicles)

Claims History Information - View Sample Response

• Claims History provides information about electronic claims that have been paid or denied, claims not paid due to full payment by other insurance or deductible requirements, and pending claims. Claims History includes viewing the statuses of all claims (paper and/or electronic; assigned and/or non-assigned). The last 18 months of claims history is available with the exception of claims transferred from another jurisdiction, which are only available for 45 days. Note: CSI does not display payment amounts for non-assigned claims.

Pending Claims Information - View Sample Response

• This function of CSI gives more detailed information about pending claims. The pending claims screen does not include information on a claim if a check for that claim has already been issued or if the claim has been denied.
• Pending claims fall into three categories:
  • Claims waiting for information from the Common Working File (CWF) (such as grandfathered Certificates of Medical Necessity [CMNs] or patient eligibility) before they can be processed. CWF is where master data files are kept. These master files provide CMN data and patient eligibility information.
  • Claims that have been processed but the payment has not been issued.
  • Claims which require additional information or review to complete processing, such as medical or utilization review, development letters, etc.

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• Call Cortex EDI for more details at (800) 485-5977 or email support@CortexEDI.com.

*Disclaimer: The Provider understands that receipt or use of this claim information does not guarantee payment of any health care claim and such information is subject to change, even retroactively, at any time.