Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1704 Date: March 20, 2009

Transcription

1 anual ystem Pub edicare laims Processing Department of Health & Human ervices (DHH) enters for edicare & edicaid ervices () Transmittal 1704 Date: arch 20, 2009 hange equest 6343 ubject: odifications to the National oordination of Benefits greement (OB) rossover Process. UY OF HNGE: Through this instruction, is requiring the ommon Working File (WF) to display all OB bypass exclusion indicators within the Health nsurance aster ecord (H) claim detail screens. n addition, through this instruction 1) the WF maintainer shall now begin to display crossover disposition indicators on H even when OB trading partners are in "test" mode with the OB, with one noted exception; 2) Part shared system shall modify the formatting of the special provider notification letters that it creates following Part contractor receipt of oordination of Benefits ontractor Detailed Error eports (OB DEs); and 3) at s direction, the oordination of Benefits ontractor (OB) will modify the OB nsurance File (OF) to allow for separate displays of Test/Production indicator claim versions; and expand the bytes available for "error description" within the OB Detailed Error eport layouts for 837 institutional and professional claims. New / evised aterial Effective Date: July 1, 2009, for, V, and WF; October 1, 2009, for F mplementation Date: July 6, 2009 ( and V full implementation; WF full implementation except consistency edits); October 5, 2009 (F full implementation; V hours for testing; WF implementation of consistency edits) Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. HNGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Per ow. /N/D hapter / ection / ubsection / Title 27/80.14/ onsolidated laims rossover Process 27/80.15/ laims rossover Disposition and oordination of Benefits greement By-Pass ndicators 28/70.6.1/ The oordination of Benefits greement (OB) Detailed Error eport Notification Process. FUNDNG: ETON : For Fiscal ntermediaries and arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. ETON B: For edicare dministrative ontractors (s):

2 The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTHENT: Business equirements anual nstructions *Unless otherwise specified, the effective date is the date of service.

3 ttachment - Business equirements Pub Transmittal: 1704 Date: arch 20, 2009 hange equest: 6343 UBJET: odifications to the National oordination of Benefits greement (OB) rossover Process Effective Date: July 1, 2009, for, V, and WF; October 1, 2009, for F mplementation Date: July 6, 2009 ( and V full implementation; WF full implementation except consistency edits); October 5, 2009 (F full implementation; V hours for testing; WF implementation of consistency edits). GENEL NFOTON. Background: urrently, the ommon Working File (WF) system posts the crossover disposition of the vast majority of claims that edicare contractors transmit to it for verification and validation purposes. n this vein, WF presently posts a 1 or 2-byte crossover disposition indicator in association with claims stored on history if the oordination of Benefits greement (OB) trading partner that has identified beneficiaries for crossover purposes is in production mode with the oordination of Benefits ontractor (OB). WF presently bypasses certain claims from eligibility for the national OB crossover process (e.g., requests for anticipated payment [Ps]) without posting bypass indicators on the Health nsurance aster ecord (H) and also processes, in accordance with past guidance, test crossover claims through for the OB process without posting disposition indicators in association with these claims on H. These practices will change effective with this instruction. ll edicare contractors currently generate special provider notification letters when the OB transmits Health nsurance Portability and ccountability ct (HP) merican National tandards nstitute (N) 837 compliance errors (or 222 errors) and OB trading partner disputes errors ( 333 errors) to them via the OB Detailed Error eport process. These letters contain information about the affected beneficiaries, their associated claims, and the affected provider as well as the specific error code and accompanying description that explains why was unable to transmit the affected claims to the OB trading partner via the national crossover process. edicare Part contractors currently issue reports that mimic the oordination of Benefits ontractor Detailed Error eport (OB DE) to providers when they learn that either the OB or OB trading partner could not accept crossover claims. The current 114 report is unwieldy and does not feature a pre-printing of the provider address. therefore is requesting that the Part shared system reduce the manual effort that its associated contractors must expend in mailing the OB DE special provider report by making the changes indicated in the business requirements below. Lastly, has identified a need to expand the OB Detailed Error eport error description field in association with 837 institutional and professional claims. This business need is addressed in the requirements below. mplementation strategy for this instruction: s indicated with the effective and implementation dates above, all shared systems, except the WF, will implement all requirements except and as part of the July 2009 release. WF shall implement formatting changes associated with the business requirements below during July 2009 but shall implement consistency edit requirements during the October 2009 release. ll shared systems shall implement requirements tied to and as part of the October 2009 release. B. Policy: Effective with the July 2009 release, the WF maintainer shall display all auto-exclude/ob by-pass events, as detailed below, in association with an adjudicated claim within the OB bypass field on

4 page 3 of the H intermediary claim detail screen and on page 2 of the H Part B and Durable edical Equipment edicare dministrative ontractor (DE ) detail screen. The WF shall, in addition, display a new BT crossover disposition exclusion indicator on pages 2 and 3 of the H claim detail screens. s part of the October 2009 release, WF shall discontinue the practice of inputting spaces on the claim detail records when the incoming claim contains invalid values within specifically-designated fields. WF shall henceforth apply consistency edits to the following fields of the incoming claims transactions indicated: 1) adjustment indicator field (valid values= or space) within HUP, HUOP, HUHH, HUH, HUB, and HUD claims; 2) NP placeholder field (valid values=y or space) within HUP, HUOP, HUHH, HUH, HUB, and HUD claims; 3) Beneficiary Liability indicator field (valid values=l, N, or space) within HUB and HUD claims (NOTE: WF already applies consistency edits to incoming Part -oriented claims); and 4) PQ indicator (valid values=q or space) within HUB claims. Upon receipt of a consistency edit for the reporting of invalid values within the foregoing claim fields, the contractor, working with its shared system, shall, as of the October 2009 release, take the following actions: 1) fix the incorrect application of non-valid values within the applicable claim fields; and 2) retransmit the corrected claims to WF. Through this instruction, the WF maintainer shall, as part of the July 2009 release, create additional fields within claim page 3 of the H intermediary claim detail screen and page 2 of the Part B and DE claim detail screens to allow for the reporting of crossover disposition indicators in association with test OB crossover claims. s occurs presently, the WF maintainer shall determine that a OB trading partner is in test mode by referencing the incoming OB nsurance File (OF). The WF maintainer shall 1) create additional fields for displaying test crossover disposition indicators within both the eligibility filebased and claim-based crossover portions of the claim detail screens on H; and 2) display the test crossover disposition indicators so that they mirror all such indicators used for production claims in association with the following four (4) claim versions: 40101, 5010, National ouncil for Prescription Drug Programs (NPDP)-5.1, and NPDP-D.0. f the OB transmits a OF that contains a OB D within the range through (edicaid quality project), WF shall post an Q disposition indicator in association with the claim instead of the traditional indicator when it selects the claim for crossover. (NOTE: Q shall designate that edicare is transferring the claim for edicaid quality project purposes only.) WF shall annotate claims whose OB D is through with Q regardless of the claim version indicator in those instances where it selects the claims for transference to the OB. f WF excludes from crossover a claim whose OB D equals through 79999, WF shall continue to post the crossover disposition indicator that corresponds to the reason for the exclusion on the appropriate H claim detail screen. t s direction, the OB will modify the OF, in accordance with ttachment, so that the current Test/Production indicator field is renamed the Test/Production ndicator and a new NPDP 5.1 Test/Production ndicator is reflected. WF shall 1) accept and process the OB-generated modified OF on a weekly basis; and 2) accept the following values within the two newly defined OF fields: N (format not in use for this trading partner); P (trading partner in production); and T (trading partner in test mode). n addition, WF shall modify the BO reply trailer (29) in the following manner: 1) ename OB-TET-POD-ND P as OB TET-POD-ND P ; 2) ename NPDP-TET-POD-ND P as NPDPD.0-TET-POD- ND P ; and 3) dd NPDP5.1-TET-POD-ND P (see ttachment B). The shared systems shall accept and utilize the modified WF-generated BO reply trailer (29) as part of the national OB crossover process. (NOTE: pecific scenarios involving the interaction of new indicators, as well as pre-existing indicators, are covered under change requests 6308 and 6374, the latter of which is in final clearance. dditionally, WF shall modify the H OF File ummary creen (OB) as follows on page 3: 1) ename 4010 TT/PD as TET/PD : 2) ename NPDP TT/PD as NPDP D.0 TT/PD ; and 3) dd NPDP5.1 TT/PD.

5 The OB will, at s direction, modify the OB Detailed Error eport layouts for 837 institutional and professional claims to expand the size of the error description field and to increment the filler field at the detail record level, as reflected in ttachment. ll shared system maintainers shall modify their version of the OB Detailed Error eport layouts to coincide with the formats found in ttachment. Upon receipt of the OB Detailed Error eport (DE), the Part shared system shall configure the existing 114 report, as derived from the OB DE, so that it 1) continues to display in landscape format; and 2) includes a cover page that contains the provider s correspondence mailing address.. BUNE EQUEENT TBLE Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other The WF maintainer shall display up to 8 new OB bypass indicators in association with an adjudicated claim within the OB bypass field on page 3 of the H intermediary claim detail screen and on page 2 of the H Part B and DE claim detail screens The WF maintainer shall display the following new 2- byte OB bypass indicators in the OB bypass field on page 3 of the H intermediary claim detail screen: B --laim represents dd History only; therefore, the claim is bypassed and not crossed over; BB laim falls into one of two situations: 1) there is no eligibility record; and 2) the only available eligibility record contains a Y delete indicator; therefore, the claim is bypassed for crossover; B laim represents an abbreviated encounter record (TOB 11z; condition code 04 or 69); therefore, the claim is bypassed and not crossed over; BD laim contains a Part WF claim disposition other than 01, 03, or 05; therefore, the claim is bypassed and not crossed over; BE ubmission of Notice of Elections (Hospice TOB=8x through 8xE on HUH; EPP TOB=11 through 11D on HUP; eligious Non-edical are TOB=41, 41B, and 41D on HUP; edicare oordination are TOB=89 and 89B on HUOP); therefore, the submission is bypassed and not crossed over; BF laim represents an excluded E H H F V W F

6 Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other demonstration (DEO) project; therefore, the claim is bypassed and not crossed over; BP anctioned provider claim during the service dates indicated; therefore, the claim is bypassed and not crossed over; and B ubmission for equest for nticipated Payment [P] claims (TOB=322 and 332); therefore, the submission is bypassed and not crossed over. E H H F V W F The WF maintainer shall display the following new 2- byte OB bypass indicators in the OB bypass field on page 2 of the H Part B and DE claim detail screens: B --laim represents dd History only; therefore, the claim is bypassed and not crossed over; BB laim falls into one of two situations: 1) there is no eligibility record; and 2) the only available eligibility record contains a Y delete indicator; therefore, the claim is bypassed and not crossed over; BD laim contains a Part B or DE WF claim disposition other than 01, 03, or 05; therefore, the claim is bypassed and not crossed over; BF laim represents an excluded demonstration (DEO) project; therefore, the claim is bypassed and not crossed over; and BP anctioned provider claim during the service dates indicated; therefore, the claim is bypassed and not crossed over The WF maintainer shall display the value BT ndividual OB D did not have a matching OF as a crossover disposition exclusion indicator within the eligibility-based and claim-based portions of pages 2 and 3 of the H claim detail screens The contractor responsible for the Next Generation Desktop (NGD) shall modify its application screens and accompanying documentation to reflect the foregoing OB bypass indicators, as found in requirements NGD ontractor

7 Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other and The contractor responsible for the NGD shall modify its application screens and accompanying documentation to reflect the new BT crossover disposition indicator, together with its definition, as per The contractor or system responsible for the DT application shall update that tool to capture the OB bypass indicators, as found in and The contractor or system responsible for the DT application shall update that tool to capture the new BT claims crossover disposition indicator, together with its definition, as per ontractors shall update their provider customer service materials to include the above OB bypass indicators and new BT crossover disposition indicator along with their descriptions WF shall discontinue the practice of inputting spaces on the claim detail records when the incoming claim contains invalid values within specifically-designated fields WF shall henceforth apply consistency edits to the following fields of the incoming claims transactions indicated: adjustment indicator field (valid values= or space) within HUP, HUOP, HUHH, HUH, HUB, and HUD claims; NP placeholder field (valid values=y or space)within HUP, HUOP, HUHH, HUH, HUB, and HUD claims; Beneficiary Liability indicator field (valid values=l, N, or space) within HUB and HUD claims; and PQ indicator (valid values=q or space) within HUB claims. E H H F V W F NGD ontractor DT DT Upon receipt of a WF-generated consistency edit for inappropriate values being reported within one of the fields outlined in , the contractor, working with its shared system, shall take the following actions: Fix the incorrect application of non-valid values within the applicable claim fields; and

8 Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other etransmit the corrected claims to WF t s direction, the OB will modify the OB nsurance File (OF), in accordance with ttachment, so that the Test/Production indicator field is renamed the Test/Production indicator and a new NPDP 5.1 Test/Production ndicator is reflected WF shall accept and process the OB-generated modified OF on a weekly basis WF shall accept the following values within the OF fields discussed in : N (format not in use for this trading partner); P (trading partner in production); and T (trading partner in test mode) WF shall utilize the modified OF in association with its posting of test crossover disposition indicator requirements and sub-requirements, beginning with WF shall modify the BO reply trailer (29) as follows as reflected in ttachment B: ename OB-TET-POD-ND P as TET-POD-ND P ; ename NPDP-TET-POD-ND P as NPDPD0-TET-POD-ND P ; and dd NPDP51-TET-POD-ND P (see ttachment B). (NOTE: ll other elements shall remain unchanged.) WF shall modify the H OF File ummary creen (OB) as follows on page 3: ename 4010 TT/PD as TET/PD : ename NPDP TT/PD as NPDP D.0 TT/PD ; and dd NPDP5.1 TT/PD. E H H F V W F OB ll shared systems indicated, as well as the contractor responsible for maintaining the DT application, shall modify their interfaces with the H OB so that they capture the changes described in The shared systems shall accept and utilize the modified WF-generated BO reply trailer (29) as part of the national OB crossover process. (NOTE: pecific scenarios involving the interaction of new indicators, as DT

9 Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other well as pre-existing indicators, are covered under change request 6308 and will be addressed as part of change request 6374 when final.) The contractor responsible for maintaining the NGD application shall modify all OF-related screens to correspond to the above described changes The contractor responsible for the DT application shall modify all OF-related screens to correspond to the above described changes The WF maintainer shall create additional fields within claim page 3 of the H intermediary claim detail screen and page 2 of the Part B and DE claim detail screens to allow for the reporting of crossover disposition indicators in association with test OB crossover claims The shared systems shall adjust their interfaces with H to meet the requirements of The WF maintainer shall determine that a OB trading partner is in test mode by reading the OF The WF maintainer shall create additional fields for displaying test crossover disposition indicators within both the eligibility file-based and claim-based crossover portions of the claim detail screens on H The shared systems shall adjust their interfaces with H to meet the requirements of The WF maintainer shall display test crossover disposition indicators so that they mirror all such indicators used for production claims in association with the following claim versions: 40101, 5010, NPDP-5.1, and NPDP-D f the OB transmits a OF that contains a test OB D within the range through (edicaid quality project), WF shall post an Q disposition indicator in association with the claim instead of the traditional indicator when it selects the claim for crossover. (NOTE: Q shall designate that edicare is transferring the claim for edicaid quality project purposes only.) WF shall annotate claims whose OB D is through with Q regardless of the claim version indicator in those instances where it selects the claims for transference to the OB. E H H F V W F NGD DT

10 Number equirement esponsibility (place an in each applicable column) / B D E F hared- ystem aintainers Other f WF excludes from crossover a claim whose OB D equals through 79999, WF shall continue to post the crossover disposition indicator that corresponds to the reason for the exclusion on the appropriate H claim detail screen The shared systems shall adjust their interfaces with H to meet the requirements of t s direction, the OB shall modify the OB Detailed Error eport layouts for 837 institutional and professional claims to expand the size of the error description field at the detail record level, as reflected in ttachment The indicated shared system maintainers shall modify their versions of the OB Detailed Error eport layouts to coincide with the formats found in ttachment. (NOTE: This means that the shared systems shall include the expanded error description code as part of their special provider notification letters.) Upon receipt of the OB Detailed Error eport (DE), the Part shared system shall configure the existing 114 report, as derived from the OB DE, so that it 1) continues to display in landscape format; and 2) includes a cover page that contains the provider s correspondence mailing address s occurs currently, all Part contractors shall ensure that the newly formatted special provider notification letters are printing correctly and are ready for mailing ll Part contractors shall notify the shared system maintainer of instances where the generated special letters cannot be utilized due to problems with formatting or printing so that steps can be undertaken to correct the concerns as soon as possible. E H H F V W F OB. POVDE EDUTON TBLE Number equirement esponsibility (place an in each applicable column) / B D E F H H hared- ystem aintainers Other

11 None. F V W F V. UPPOTNG NFOTON ection : ecommendations and supporting information associated with listed requirements: "hould denotes a recommendation. -ef equirement Number N/ ecommendations or other supporting information: ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Brian Pabst (brian.pabst@cms.hhs.gov; ) Post-mplementation ontact(s): Brian Pabst (brian.pabst@cms.hhs.gov; ) V. FUNDNG ection : For Fiscal ntermediaries, egional Home Health ntermediaries and arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: For edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTHENT

12 OB NUNE FLE TTHENT Field tart Length End Description OB D Unique identifier for each OB greement OB TN Tax dentification Number of OB OB Name Name of OB Partner (Equivalent to nsurer Name on BO uxiliary File) OB ddress ddress 1 of OB OB ddress ddress 2 of OB OB ity ddress city of OB OB tate Postal tate bbreviation of OB OB Zip Zip plus 4 of OB ommon laim Exclusions The following fields are 1 byte indicators dictating type of claim exclusions. value of 'Y' in any of the following fields indicates those types of claims should be excluded. Non-assigned Non-assigned claims Orig. laims Paid at 100% Original claims paid at 100% Orig. laims Paid at >100% of the submitted.charges w/out deductible or co-ins Original claims paid at greater than 100% of the submitted charges without deductible or coinsurance remaining (NOTE: lso covers the exclusion of ambulatory surgical center claims, even if deductible or co-insurance applies.) 100% Denied laims, No % denied claims, with no additional beneficiary liability dditional Liability 100% Denied laims, dditional Liability % denied claims, with additional beneficiary liability djustment laims, onetary djustments, monetary claims djustment laims, Non djustments, non-monetary/statistical claims onetary/tatistical P laims edicare econdary Payer (P) claims. Other nsurance laims if other insurance (such as edigap, supplemental, TE, or other) exists for beneficiary. **pplies to tate edicaid gencies only. ** NPDP laims National ouncil Prescription Drug Program laims djustment laims Paid at djustment claims paid at 100%. 100% djustment laims, 100% djustment laims, 100% Denied, with no additional beneficiary Denied, No dditional Liability liability djustment laims, 100% Denied, dditional Liability djustment laims, 100% Denied, with additional beneficiary liability P ost-voided laims P claims that have been cost-avoided. ass djustment laim- PF ass adjustment claim tied to edicare Physician Fee chedule (PF) updates. ass djustment laim-other ass adjustment claim-all other reasons besides PF updates. ll djustment laims ll djustment laims (NOTE: does not include credit only adjustments true voids for Part ) ecovery udit ontractor () djustment laims () ndicates that OB trading partner wishes to exclude all recovery audit contractor () adjustment claims (acceptable values= Y or space) Filler Future Hospital npatient TOB 11 - Hospital: npatient Part Hospital npatient B TOB 12 - Hospital: npatient Part B Hospital Outpatient TOB 13 - Hospital: Outpatient Hospital Other B TOB 14 - Hospital: Other Part B (Non-patient) Hospital wing TOB 18 - Hospital: wing Bed NF npatient TOB 21 - killed Nursing Facility: npatient Part

13 NF npatient B TOB 22 - killed Nursing Facility: npatient Part B NF Outpatient TOB 23 - killed Nursing Facility: Outpatient NF Other B TOB 24 - killed Nursing Facility: Other Part B (Non-patient) NF wing Bed TOB 28 - killed Nursing Facility: wing Bed Home Health B TOB 32 - Home Health: Part B Trust Fund Home Health TOB 33 - Home Health: Part Trust Fund Home Health Outpatient TOB 34 - Home Health: Outpatient eligious Non-ed Hospital TOB 41 - hristian cience/eligious Non-edical ervices (Hospital) linic ural Health TOB 71 - linic: ural Health linic Freestanding Dialysis TOB 72 - linic: Freestanding Dialysis linic Fed Health enter TOB 73 - linic: Federally Qualified Health enter linic Outpatient ehab TOB 74 - linic: Outpatient ehabilitation Facility linic OF TOB 75 - linic: omprehensive Outpatient ehabilitation Facility (OF) linic omp ental Health TOB 76 - linic: omprehensive ental Health linic linic Other TOB 79 - linic: Other F Hospice Non-Hospital TOB 81 - pecial Facility: Hospice Non-Hospital F Hospice Hospital TOB 82 - pecial Facility: Hospice pecial Facility: Hospice Hospital mbulatory urgical enter TOB 83 - pecial Facility: mbulatory urgical enter Primary are Hospital TOB 85 - Primary are Hospital laim Header Level Exclusions The following fields are 1 byte indicators dictating type of claim exclusions. value of 'Y' in any of the following fields indicates those types of claims should be excluded. ll Part laims laims identified as Part in the HUP, HUOP, HUHH, and HUH queries to WF. ll Part B laims laims identified as Part B in the HUB query to WF. ll DE laims laims identified as DE in the HUD query to WF. Filler Filler Part /HH Provider nclusion/exclusion Part /HH claims may be included or excluded by providers by specifying the nclusion/exclusion type. nclusion or exclusion may be limited by either provider D or provider state. nclusion/exclusion Type ndicates whether providers are to be included or excluded ( - nclusion or E - Exclusion) Provider Qualifier ndicates whether providers are identified by state or by provider D (P - Provider number or - Provider state) Provider D (P) pecific providers Ds to be included or excluded (occurs 50 times--13-digit alpha/numeric provider number. Provider tate () pecific provider states to be included or excluded (occurs 50 times 2-digit provider state code) djustment laims, ass djustment laims, and ecovery udit ontractor djustment () laims nclusion nclusion ndicator (used for trading partners wishing to receive adjustment claims only) ass djustment laims- PF Updates ndicates that OB trading partner wishes to include adjustment claims ONLY(acceptable values= or space) ndicates that OB trading partner wishes to include all mass adjustment claims tied to edicare Physician Fee chedule (PF) updates (acceptable values= Y or space)

14 ass djustment laims Other ecovery udit ontractor () djustment laims () ndicates that OB trading partner wishes to include all mass adjustment claims other (acceptable values= Y or space) ndicates that OB trading partner wishes to include all recovery audit contractor () adjustment claims (acceptable values= Y or space) Filler Future Part B ontractor nclusion/exclusion pecific contractors may be included or excluded on Part B claims by specifying the nclusion/exclusion type. nclusion/exclusion Type ndicates whether contractors are to be included or excluded ( nclusion or E - Exclusion) ontractor D tate-specific Part B contractor claims to be excluded (occurs 50 times. First 2 positions of B indicator.) Filler Future DE ontractor pecific contractors may be excluded on DE claims. Exclusion ontractor D pecific contractors to be excluded on DE claims (occurs 4 times). HP 5010 & NPDP D.0 Test/Production ndicator 5010 Test/Production ndicator NPDP D.0 Test/Production ndicator OB trading partner status for acceptance of HP 5010 (acceptable values= N--not ready or not applicable; T--Test mode; P--Production mode) OB trading partner status for acceptance of NPDP D.0 (acceptable values= N--not ready or not applicable; T--Test mode; P--Production mode) NPDP 5.1 Test/Production ndicator NPDP 5.1 Test/Production ndicator OB trading partner status for acceptance of NPDP version 5.1 claims (acceptable values=n format not in use; T Test mode; P Production mode) Filler Future edicare ummary Notice (N) ndicator for Trading Partner Name N ndicator for Printing of Trading Partner Name ndicates whether the OB trading partner wishes its name to appear on the N. (Y=Yes N=No) Test/ Production ndicator Test/Production ndicator One-position indicator that communicates a OB trading partner s status for acceptance of HP claims (T= Test ode; P=Production ode; N=format not in use)

15 WF Beneficiary Other nsurance (BO) eply Trailer equirements ttachment B WF shall return a BO eply Trailer 29 to the edicare contractors that displays the following elements as part of the national oordination of Benefits greement (OB) eligibility file-based and edigap claim-based crossover processes: 01: :-29-TLE. 05: :-29-TL-ODE P (02). 05: :-29-OUENE P 9(02). 05: :-29-OB-O-ND P (01). 05: :-29-DT OU 1 TO 10 TE, DEPENDNG ON :-29-OUENE NDEED: :-29-NDE. 10: :-29-OB-NU P (10). 10: :-29-OB-NE P (32). 10: :-29-OB-N-ND P (01). 10: :-29-OB-EFF-DTE P 9 (07) OP-3. 10: :-29-OB-T-DTE P 9 (07) OP-3. 10: : TET-POD-ND P (01) 10: : TET-POD-ND P (01) 10: :-29-NPDP D0-TET-POD-ND P (01) NPDP 51-TET-POD-ND P (01) 10: :-filler P (9)

16 TTHENT OB Detailed Error eport nstitutional Error File Layout (Detail ecord) 1. Date ontrol Number OB-D ubscriber D/HN laim DN/N ecord Number ecord/loop dentifier egment Element Error ource ode ( 111, 222, or 333 ) 11. Error/Trading Partner Dispute ode Filler Field ontents BHT 03 dentifier laim DN/N Error Description Filler nstitutional Error File Layout (ummary ecord) 1. Date Total Number of laims For Processing Date Number of 111 Errors Number of 222 Errors Percentage of 222 Errors Number of 333 Errors Percentage of 333 Errors Filler ummary ecord d (Error ource ode) ( 999 ) 10. Filler

17 OB Detailed Error eport Professional Error File Layout (Detail ecord) 1. Date ontrol Number OB-D ubscriber D/HN laim DN/N ecord Number ecord/loop dentifier egment Element Error ource ode ( 111, 222, or 333 ) 11. Error/Trading Partner Dispute ode Filler Field ontents BHT 03 dentifier laim DN/N Error Description Filler Professional Error File Layout (ummary ecord) 1. Date Total Number of laims For Processing Date Number of 111 Errors Number of 222 Errors Percentage of 222 Errors Number of 333 Errors Percentage of 333 Errors Filler ummary ecord d (Error ource ode) ( 999 ) 10. Filler

18 onsolidated laims rossover Process (ev. 1704, ssued: , Effective: , V, WF/ F, mplementation: , V, WF/ F, V, WF). The echanics of the WF laims election Process and BO and laim-based eply Trailers 1. WF eceipt and Processing of the oordination of Benefits greement nsurance File (OF) Effective July 6, 2004, the OB will begin to send copies of the oordination of Benefits greement nsurance File (OF) to the nine WF host sites on a weekly basis. The OF will contain specific information that will identify the OB trading partner, including name, OB D, address, and tax identification number (TN). t will also contain each trading partner s claims selection criteria exclusions (claim or bill types that the trading partner does not want to receive via the crossover process) along with an indicator (Y=Yes; N=No) regarding whether the trading partner wishes its name to be printed on the edicare ummary Notice (N). During the OB parallel production period, which is estimated to run from July 6, 2004, to October 1, 2004, WF will exclusively return an N N indicator to the edicare contractor. The WF shall load the initial OF submission from OB as well as all future weekly updates. Upon receipt of a claim, the WF shall take the following actions: a. earch for a OB eligibility record on the BO auxiliary record for each beneficiary, unless there is a OB D in range through present on the incoming HUB or HUD claim (which identifies edigap claimbased crossover), and obtain the associated OB D(s) NOTE: There may be multiple OB Ds; b. efer to the OF associated with each OB D (NOTE: WF shall pull the OB D from the BO auxiliary record) to obtain the OB trading partner s name and claims selection criteria; c. pply the OB trading partner s selection criteria; and d. Transmit a BO reply trailer 29 to the edicare contractor only if the claim is to be sent, via 837 OB flat file or National ouncil for Prescription Drug Programs (NPDP) file, to the OB to be crossed over. (ee Pub , hap. 28, 70.6 for more information about the claim file transmission process involving the edicare contractor and the OB.) Effective with the October 2004 systems release, WF shall read the OF submission to determine whether a Test/Production ndicator T (test mode) or P (production mode) is

19 present. WF will then include the Test/Production ndicator on the BO reply trailer 29 that is returned to the edicare contractor. (ee additional details below.) Effective with July 7, 2009, at s direction, the OB will modify the OF so that the Test/Production indicator, originally created as part of the October 2004 release, is renamed the Test/Production indicator and a new field, the NPDP-5.1 Test/Production indicator, is also reflected. n turn, WF shall 1) accept and process the OB-generated modified OF on a weekly basis; and 2) accept the following values within the two newly defined OF fields: N (format not in use for this trading partner); P (trading partner in production); and T (trading partner in test mode).. WF shall also modify the BO reply trailer (29) to reflect these changes, as further specified under BO eply Trailer 29 Processes below. 2. BO eply Trailer 29 Processes For purposes of eligibility file-based crossover, if WF selects a claim for crossover, it shall return a BO reply trailer 29 to the edicare contractor. The returned BO reply trailer 29 shall include, in addition to OB D(s), the OB trading partner name(s), an crossover indicator that specifies that the claim has been selected to be crossed over, the insurer effective and termination dates, and a 1-digit indicator [ Y =Yes; N =No] that specifies whether the OB trading partner s name should be printed on the beneficiary N. Effective with the October 2004 systems release, WF shall also include a 1-digit Test/Production ndicator T (test mode) or P (production mode) on the BO reply trailer 29 that is returned to the edicare contractor. Effective with July 7, 2009, WF shall modify the BO reply trailer (29) to rename the existing Test/Production indicator as Test/Production indicator and rename the NPDP Test/Production indicator as NPDPD0 Test/Production indicator. n addition, WF shall include a new 1-byte field NPDP51 Test/Production indicator as part of the BO reply trailer (29). B. N rossover essages s specified above, during the OB parallel production period (July 6, 2004, to October 1, 2004), WF will exclusively return an N N indicator via the BO reply trailer, in accordance with the information received via the OF submission. f a edicare contractor receives a Y N indicator during the parallel production period, it shall ignore it. Beginning with the October 2004 systems release, when a contractor receives a BO reply trailer 29 from WF that contains a Test/Production ndicator T (test mode), it shall ignore the N ndicator provided on the trailer. nstead, the edicare contractor shall follow its existing procedures for inclusion of trading partner names on Ns for those trading partners with whom it has existing Trading Partner greements (TPs).

20 Beginning with the October 2004 systems release, when a contractor receives a BO reply trailer 29 from WF that contains a Test/Production ndicator P (production mode), it shall read the N indicator (Y=Yes, print trading partner s name; N=Do not print trading partner s name) returned on the BO reply trailer 29. (efer to Pub.100-4, chapter 28, 70.6 for additional details.) Effective January 5, 2009, when WF returns a BO reply trailer (29) to a edicare contractor that contains only a OB D in the range through 89999, the contractor s system shall suppress all crossover information, including name of insurer and generic message#35.1, from all beneficiary Ns. (ee chapter 28, 70.6 for details regarding additional edicare contractor requirements.) n addition, the contractor shall not issue special provider notification letters following their receipt of OB Detailed Error eports when the claim s associated OB D is within the range through (see chapter 28, for more details.). Electronic emittance dvice (835)/Provider emittance dvice rossover essages Beginning with the October 2004 release, when WF returns a BO reply trailer (29) that contains a T Test/Production ndicator to the edicare contractors, they shall not print information received from the BO reply trailer (29) in the required crossover fields on the 835 Electronic emittance dvice or other provider remittance advice(s) that is/are in production. ontractors shall, however, populate the 835 E (or provider remittance advice(s) in production) with required crossover information when they have existing agreements with trading partners. Beginning with the October 2004 release, when WF returns a BO reply trailer (29) that contains a P Test/Production ndicator to the edicare contractors, they shall use the returned BO trailer information to take the following actions on the provider s 835 Electronic emittance dvice: 1. ecord code 19 in LP-02 (laim tatus ode) in Loop 2100 (laim Payment nformation) of the 835 E (v ). [NOTE: ecord 20 in LP-02 (laim tatus ode) in Loop 2100 (laim Payment nformation) when edicare is the secondary payer.] 2. Update the 2100 Loop (rossover arrier Name) on the 835 E as follows: N101 [Entity dentifier ode] Use TT, as specified in the 835 mplementation Guide. N102 [Entity Type Qualifier] Use 2, as specified in the 835 mplementation Guide.

21 N103 [Name, Last or Organization Name] Use the OB trading partner s name that accompanies the first sorted OB D returned to you on the BO reply trailer. N108 [dentification ode Qualifier] Use P (Payer dentification.) N109 [dentification ode] Use the first OB D returned to you on the BO reply trailer. (ee line 24 of the BO aux. file record. f the 835 E is not in production and the contractor receives a P Test/Production ndicator, it shall use the information provided on the BO reply trailer (29) to populate the existing provider remittance advices that it has in production. Effective January 5, 2009, if WF returns only a OB D range through on a BO reply trailer (29) to a edicare contractor, the contractor s system shall suppress all crossover information (the entire 2100 loop) on the 835 E. Effective January 5, 2009, when a beneficiary s claim is associated with more than one OB D (i.e., the beneficiary has more than one health insurer/benefit plan that has signed a national OB), WF shall sort the OB Ds and trading partner names in the following order: 1) Eligibility-based edigap ( ); 2) laim-based edigap ( ); 3) upplemental ( ); 4) TE ( ); 5) Other nsurer ( ); 6) edicaid ( ); and 7) Other Health are Pre- Payment Plan [HPP] ( ). When two or more OB Ds fall in the same range (see item 24 in the BO uxiliary File table above), WF shall sort numerically within the same range. 3. WF Treatment of Non-assigned edicaid laims When WF receives a non-assigned edicare claim for a beneficiary whose BO auxiliary record contains a OB D with a current effective date in the edicaid eligibility-based range ( ), it shall reject the claim by returning edit 5248 to the Part B contractor s system only when the edicaid OB trading partner is in production mode (Test/Production ndicator=p) with the OB. t the same time, WF shall only return a edicaid reply trailer 36 to the Part B contractor that contains the trading partner s OB D and beneficiary s effective and termination dates under edicaid when the edicaid OB trading partner is in production mode with the OB. WF shall determine that a edicaid trading partner is in production mode by referring to the latest OB nsurance File (OF) update it has received. f, upon receipt of WF edit 5248 and the edicaid reply trailer (36), the Part B contractor determines that the non-assigned claim s service dates fall during a period when the beneficiary is eligible for edicaid, it shall convert the assignment indicator from nonassigned to assigned and retransmit the claim to WF. fter the claim has been

22 retransmitted, the WF will only return a BO reply trailer to the Part B contractor if the claim is to be sent to the OB to be crossed over. Effective with October 1, 2007, WF shall cease returning an edit 5248 and edicaid reply trailer 36 to a Durable edical Equipment edicare dministrative ontractor (D). n lieu of this procedure, WF shall only return a BO reply trailer (29) to the D for the claim if the OB nsurance File (OF) for the tate edicaid gency indicates that the entity wishes to receive non-assigned claims. NOTE: ost edicaid agencies will not accept such claims for crossover purposes. f WF determines via the corresponding OF that the tate edicaid gency does not wish to receive non-assigned claims, it shall exclude the claim for crossover. n addition, WF shall mark the excluded claim with its appropriate claims crossover disposition indicator (see of this chapter for more details) and store the claim with the information within the appropriate Health nsurance aster ecord (H) detailed history screen. Ds shall no longer modify the provider assignment indicator on incoming nonassigned supplier claims for which there is a corresponding OB D in the edicaid range ( ). 4. dditional nformation ncluded on the HUP, HUOP, HUHH, HUH, HUB and HUD Queries to WF Beneficiary Liability ndicators on Part B and D WF laims Transactions Effective with the January 2005 release, the Part B and D systems shall be required to include an indicator L (beneficiary is liable for the denied service[s]) or N (beneficiary is not liable for the denied service[s]) in an available field on the HUB and HUD queries to WF for claims on which all line items are denied. The liability indicators (L or N) will be at the header or claim level rather than at the line level. urrently, the D shared system is able to identify, through the use of an internal indicator, whether a submitted claim is in the National ouncil for Prescription Drug Programs (NPDP) format. The D shared system shall pass an indicator P to WF in an available field on the HUD query when the claim is in the NPDP format. The indicator P shall be included in a field on the HUD query that is separate from the fields used to indicate whether a beneficiary is liable for all services denied on his/her claim. The WF shall read the new indicators passed via the HUB or HUD queries for purposes of excluding denied services on claims with or without beneficiary liability and NPDP claims.

23 Beneficiary Liability ndicators on Part WF laims Transactions Effective with October 2007, the WF maintainer shall create a 1-byte beneficiary liability indicator field within the header of its HUP, HUOP, HUHH, and HUH Part claims transactions (valid values for the field=l or N). s Part contractors adjudicate claims and determine that the beneficiary has payment liability for any part of the fully denied services or service lines, they shall set an L indicator within the newly created beneficiary liability field in the header of their HUP, HUOP, HUHH, and HUH claims that they transmit to WF. n addition, as Part contractors adjudicate claims and determine that the beneficiary has no payment liability for any of the fully denied services or service lines that is, the provider must absorb all costs for the fully denied claims they shall include an N beneficiary indicator within the designated field in the header of their HUP, HUOP, HUHH, and HUH claims that they transmit to WF. Upon receipt of an HUP, HUOP, HUHH, or HUH claim that contains an L or N beneficiary liability indicator, WF shall read the OB nsurance File (OF) to determine whether the OB trading partner wishes to receive original fully denied claims with beneficiary liability (crossover indicator G ) or without beneficiary liability (crossover indicator F ) or adjustment fully denied claims with beneficiary liability (crossover indicator U ) or without beneficiary liability (crossover indicator T ). WF shall deploy the same logic for excluding Part fully denied original and adjustment claims with or without beneficiary liability as it now utilizes to exclude fully denied original and adjustment Part B and D/DE claims with and without beneficiary liability, as specified elsewhere within this section. f WF determines that the OB trading partner wishes to exclude the claim, as per the OF, it shall suppress the claim from the crossover process. WF shall post the appropriate crossover disposition indicator in association with the adjudicated claim on the H detailed history screen (see of this chapter). n addition, the WF maintainer shall create and display the new 1-byte beneficiary liability indicator field within the H detailed history screens (NPL, OUTL, HHL, and HOL), to illustrate the indicator ( L or N ) that appeared on the incoming HUP, HUOP, HUHH, or HUH claim transaction. WF Editing for ncorrect Values f a Part contractor sends values other than L or N in the newly defined beneficiary liability field in the header of its HUP, HUOP, HUHH, or HUH claim, WF shall reject the claim back to the Part contractor for correction. Following receipt of the WF rejection, the Part contractor shall change the incorrect value placed within the newly defined beneficiary liability field and retransmit the claim to WF.