Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2076 Date: October 28, 2010

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1 anual ystem Pub edicare laims Processing Department of Health & Human ervices (DHH) enters for edicare & edicaid ervices () Transmittal 2076 Date: October 28, 2010 hange equest 7136 UBJET: odifications to the National oordination of Benefits greement (OB) rossover Process temming Principally From the ffordable are ct (). UY OF HNGE: This change request outlines several revisions that are needed within the enters for edicare and edicaid ervices" base national OB crossover program in general and accommodates specific requirements in particular. EFFETVE DTE: pril 1, 2011 PLEENTTON DTE: pril 4, 2011 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.. HNGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Per ow. /N/D HPTE / ETON / UBETON / TTLE 27/80.14/ onsolidated laims rossover Process 28/70.6.1/ oordination of Benefits greement (OB) Detailed Error eport Notification Process. FUNDNG: For Fiscal ntermediaries (Fs), egional Home Health ntermediaries (HHs) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. 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. V. TTHENT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

2 ttachment - Business equirements Pub Transmittal: 2076 Date: October 28, 2010 hange equest: 7136 UBJET: odifications to the National oordination of Benefits greement (OB) rossover Process temming Principally From the ffordable are ct () Effective Date: pril 1, 2011 mplementation Date: pril 4, GENEL NFOTON. Background: urrently, the ommon Working File (WF) reads the incoming oordination of Benefits ontractor (OB)-created oordination of Benefits greement nsurance File (OF) to determine each national OB trading partner s specific claims selection as tied to each OB D. To accommodate the inclusion or exclusion of Part specific provider identifiers (Ds), WF currently reads the numeric value reported on the OF by OB D and then interrogates the Provider D reported on the incoming HUP, HUOP, HUHH, or HUH claims transaction. For instances where a match is found, WF either includes or excludes the claim from the national crossover process, in accordance with the or E indicator that precedes the provider D value reported. Though has confirmed that the current field length for Part provider D is sufficient to hold a given National Provider dentifier (NP) for an institutional facility, recently discovered that WF is not reading both the Provider D and NP fields as part of its OB crossover claims inclusion or exclusion logic processing. The remedies this issue through this instruction. urrently, as specified within the Health nsurance Portability and ccountability ct (HP) merican National tandards nstitute (N) ccredited tandards ommittee () X12N 837 version institutional claims, the edicare Part shared system expresses covered days, non-covered days, co-insurance days, and life-time reserve (LT) days as QTY01 and QTY02 within the 2300 H (Health are nformation odes) portion of the claim. Under version 5010 of the HP N X institutional requirements, all payers, including edicare, will be required to reflect these day components appropriately as value codes, ranging from 80 to 83, within the 2300 H portion of the claim. This instruction contemplates the scenario during calendar year 2011 of what occurs when OB trading partners have migrated to version 5010 in production but the provider is continuing to submit claims in version With the passage of Public Law [Patient Protections and ffordable are ct (PP) or for short], edicare will be required to reprocess (mass adjust) hundreds of thousands of Part and B claims with service dates/dates of discharges beginning with January 1, 2010 (or earlier in certain qualified instances) over the course of 18 months. These specific requirements are outlined within The high volume adjustment actions required through PP have prompted to re-examine its strategies for systematically identifying and segmenting mass adjustment claims, such as those that edicare will create under the PP provisions. The resulting systems changes appear in the business requirements below. B. Policy: Upon receipt of either a 6-byte Online urvey, ertification, and eporting (O) provider D or a 10-digit NP, as found starting in position 225 of the OF, WF shall check both the Provider D and NP fields of the incoming HUP, HUOP, HUHH, or HUH for potential matches. f WF finds a provider D or NP match, it shall either include or exclude the claim based upon the indicator ( or E) reported in field 224 of the OF. The WF shall continue to either 1) include the claim if the indicator precedes the provider D or NP reported on the OF or 2) exclude the claim and annotate Part claims history with crossover

3 indicator K when the reported provider D or NP on the OF is identified for exclusion from the crossover process. The Part shared system shall ensure that it takes the following actions in those situations where the provider bills an 837 institutional claim to edicare in the format but the OB trading partner has migrated to the HP 5010 format for production use: onvert any incoming QTY01 and QTY02 data (covered days, non-covered days, co-insurance days, and LT days) to the appropriate corresponding value codes/amounts (value codes 80-83) within the 837 version 5010 institutional flat file. Effective with this instruction, the shared systems shall send all test and production original claims under a BHT03 that is distinct from the BHT03 created for all test and production adjustment claims. pecifically, the shared systems shall group together all test and production adjustment claims for transference to the OB by five (5) broad categories: 1) mass adjustment claims PP/other congressional imperative; 2) mass adjustment claims PF; 3) mass adjustment claims--all others; 4) recovery audit contractor ()-initiated adjustment claims; and 5) routine adjustment claims, not previously classified. To ensure continuity of processing, the shared systems shall be modified so that they create a 23 byte BHT03 identifier on all version and 5010 outbound 837 OB claims as follows: O for original claims; P for PP/other congressional imperative mass adjustment; for non-pp mass adjustments tied to edicare Physician Fee chedule (PF); for mass adjustment claims all others; for adjustment claims, and for routine adjustment claims, not previously classified. t direction, the OB shall modify its system to accept the foregoing new BHT03 values as received on incoming 837 OB flat files. The OB shall, at direction, modify the OB Detailed Error eports for institutional and professional claims to accommodate the extra 1-byte value within the BHT03. (NOTE: The overall length for the BHT03 will remain 30 bytes.) The shared systems shall modify their OB Detailed Error eports for institutional and professional claims to accommodate the extra 1-byte value within the BHT03 element. dditionally, the Durable edical Equipment edicare dministrative ontractor (DE ) shared system shall send an additional 1-byte value (defined as reserved for future use ) as spaces in field 504-F4 (essage) of its version 5.1 and D.0 NPDP flat file that it transmits to the OB for crossover purposes. The OB shall, at direction, modify the OB Detailed Error eports for NPDP claims to accommodate the extra 1-byte value within the Unique dentifier field. (NOTE: The overall field length for the Unique dentifier will remain 30 bytes.) Lastly, the DE shared system shall modify its OB Detailed Error eport process for NPDP version 5.1 and D.0 claims to accommodate 1 extra byte (defined as reserved for future use ) within the Unique dentifier portion of the NPDP claim format.. BUNE EQUEENT TBLE Number equirement esponsibility / D F B E Upon receipt of either a 6-byte O provider D or a 10-digit NP, as found starting in position 225 of the OF, WF shall check both the Provider D and NP fields of the incoming HUP, HUOP, HUHH, or HUH for potential matches. E H H hared- ystem aintainers F V W F X Other

4 Number equirement esponsibility / D F B E f WF finds a provider D or NP match, it shall either include or exclude the claim based upon the indicator ( or E) reported in field 224 of the OF The WF shall continue to either 1) include the claim if the indicator precedes the provider D or NP reported on the OF or 2) exclude the claim and annotate Part claims history with crossover indicator K when the reported provider D or NP on the OF is identified for exclusion from the crossover process The Part shared system shall ensure that it takes the following actions in those situations where the provider bills an 837 institutional claim to edicare in the format but the OB trading partner has migrated to the HP 5010 format for production use: E H H hared- ystem aintainers F X V W F X X Other onvert any incoming QTY01 and QTY02 data (covered days, non-covered days, coinsurance days, and LT days) to the appropriate corresponding value codes/amounts (value codes 80-83) within the 837 version 5010 institutional flat file The shared systems shall send all test and production original version and 5010 claims under a BHT03 that is distinct from the BHT03 created for all test and production adjustment claims pecifically, the shared systems shall group together all test and production version and 5010 adjustment claims for transference to the OB by five (5) broad categories: 1) mass adjustment claims PP/other congressional imperative; 2) mass adjustment claims PF; 3) mass adjustment claims--all others; 4) recovery audit contractor ()-initiated adjustment claims; and 5) routine adjustment claims, not previously classified To ensure continuity of processing, the shared systems shall be modified so that they create a 23 byte BHT03 identifier on all version and 5010 outbound 837 OB claims as follows: X X X X X X X X X

5 Number equirement esponsibility / D F B E E H H hared- ystem aintainers F V W F Other O for original claims; P for PP/other congressional imperative mass adjustment; for non-pp mass adjustments tied to edicare Physician Fee chedule (PF); for mass adjustment claims all others; for adjustment claims, and for routine adjustment claims, not previously classified t direction, the OB shall modify its system to accept the new BHT03 values specified in as received on incoming 837 OB flat files The OB shall, at direction, modify the OB Detailed Error eports for institutional and professional claims to accommodate the extra 1-byte value within the BHT03. (NOTE: The overall field length for the BHT03 will remain 30 bytes.) X OB X OB The shared systems shall modify their OB Detailed Error eports for institutional and professional claims to accommodate the extra 1-byte value within the BHT03 element ontractors shall perform updates as necessary to any reporting or peripheral systems that may be impacted by the above changes resulting from the inclusion of the new 23 rd byte within the BHT03 element. X X X X X X X X t direction, the OB shall modify its system to accept an additional 1-byte Unique dentifier Value within field 504-F4 (essage) of incoming version 5.1 and D.0 NPDP claims The DE shared system shall send an additional 1-byte value (defined as reserved for future use ) as spaces in field 504-F4 (essage) of its version 5.1 and D.0 NPDP flat file that it transmits to the OB for crossover purposes The OB shall, at direction, modify the OB Detailed Error eports for NPDP claims to X OB X OB

6 Number equirement esponsibility / D F B E accommodate the extra 1-byte value within the Unique dentifier field. (NOTE: The overall field length for the Unique dentifier will remain 30 bytes.) The DE shared system shall modify its OB Detailed Error eport process for NPDP version 5.1 and D.0 claims to accommodate 1 extra byte (defined as reserved for future use ) within the Unique dentifier portion of the NPDP claim format. E H H hared- ystem aintainers F V X W F Other. POVDE EDUTON TBLE Number equirement esponsibility / D F B E None. E H H hared- ystem aintainers F V W F OTH E V. UPPOTNG NFOTON ection : ny recommendations and supporting information associated with listed requirements: N/ X-ef equirement Number 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

7 ection : For Fiscal ntermediaries (Fs), egional Home Health ntermediaries (HHs), and/or 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.

8 onsolidated laims rossover Process (e.2076 ssued; , Effective: , mplementation; ). 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 claim-based 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 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.)

9 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). 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.)

10 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. 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.

11 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 non-assigned to assigned and retransmit the claim to WF. fter the claim has been 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

12 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 non-assigned 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. 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

13 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. s of January 4, 2010, WF shall read action code 8, in addition to action code 1, in association with incoming fully denied original HUP and HUOP claims. WF shall continue to read action code 1 for purposes of excluding all other fully denied original HUHH and HUH claims. (ee items J and K within this section for more specifics regarding revised logic for exclusion of fully denied HUP and HUOP adjustment claims.) 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. 5. odification to the WF nclusion or Exclusion Logic for the OB rossover Process Beginning with the October 2006 release, the WF or its maintainer shall modify its OB claims selection logic and processes as indicated below. The WF shall continue to include or exclude all other claim types in accordance with the logic and processes that it had in place prior to that release. D. New Part B ontractor nclusion or Exclusion Logic The WF shall read the first two (2) positions of the Business egment dentifier (B), as reported on the HUB claim, to uniquely include or exclude claims from state-specific Part B contractors, as indicated on the OB nsurance File (OF).

14 E. Exclusion of Fully Paid laims The WF shall continue to exclude Part B claims paid at 100 percent by checking for the presence of claims entry code 1 and determining that each claim s allowed amount equals the reimbursement amount and confirming that the claim contains no denied services or service lines. The WF shall continue to read action code 1 and determine that there are no deductible or coinsurance amounts for the purpose of excluding Part original claims paid at 100 percent. n addition, WF shall determine that the Part claim contained a reimbursement amount before excluding a claim with action code 1 that contained no deductible and co-insurance amounts and that the claim contained no denied services or service lines. laims with Fully Paid Lines, without Deductible or o-insurance emaining, and dditional Denied ervice Lines New HUB Line-Level ndicator Field Effective January 4, 2010, the WF maintainer shall create a new 1-byte liability denial indicator (LB ND) at the service line level for individually denied claim lines in association with the HUB claim transaction (valid values=b or spaces). Part B hared ystem equirements When the Part B shared system adjudicates claims where most of the claim service detail lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line that are the same as the paid amounts per line and the lines do not carry deductible or co-insurance amounts) but where some detail lines are denied, it shall take the following actions: 1) nput a B value in the newly created 1-byte LB ND field for each denied service line where the beneficiary has payment liability (NOTE: there may be multiple instances where the B value will be applied, contingent upon whether the beneficiary is liable for each of the denied service lines); 2) nput spaces in the newly created 1-byte LB ND field for each denied service line where the provider, rather than the beneficiary, is contractually liable for the denied service; and 3) Transmit the HUB claim to WF for normal verification and validation processing. WF equirements The WF system shall modify its logic for original fully paid claims, without deductible or coinsurance remaining, in association with Part B HUB claims as follows: 1) ontinue to verify the claim s entry or action code for confirmation that the claim is an original;

15 2) onfirm that the claim contains service lines where the amount allowed per line equals the amount paid per line; 3) heck for the presence of a B line LB ND in association with any of the denied service lines on the claim; 4) uppress the claim from the crossover process if the claim does not contain a B line LB ND for any of the denied service lines; and 5) elect the claim for crossover if even one of the denied lines contains a B line LB ND. Upon suppressing the Part B claim from the crossover process, WF shall annotate the claim on the Part B claim detail (PTBH) screen with a newly created F (Fully reimbursable claim containing denied lines with no beneficiary liability) claims crossover disposition indicator. (ee of this chapter for more details regarding crossover disposition indicators.) F. laims Paid at Greater than 100 Percent of the ubmitted harge The WF shall modify its current logic for excluding Part original edicare claims paid at greater than 100 percent of the submitted charges as follows: n addition to meeting the WF exclusion criteria for Part claims paid at greater than 100 percent of the submitted charges, WF shall exclude these claims only when there is no deductible or co-insurance amounts remaining on the claims. NOTE The current WF logic for excluding Part B original edicare claims paid at greater than 100 percent of the submitted charges/allowed amount (specifically, type F ambulatory surgical center claims, which typically carry deductible and co-insurance amounts) shall remain unchanged. G. laims with onetary or Non-onetary hanges The WF shall check the reimbursement amount as well as the deductible and co-insurance amounts on each claim to determine whether a monetary adjustment change to an original Part, B, or D claim occurred. To exclude non-monetary adjustments for Part, B, and D claims, the WF shall check the reimbursement amount as well as the deductible and co-insurance amounts on each claim to confirm that there were no monetary changes on the adjustment claim as compared to the original claim. Effective with pril 1, 2008, the WF shall also include total submitted/billed charges as part of the foregoing elements used to exclude adjustment claims, monetary as well as adjustment claims, non-monetary. (ee sub-section N, Overarching djustment laim Exclusion Logic,

16 for details concerning the processes that WF shall follow when the OB trading partner s OF specifies exclusion of all adjustment claims.) H. Excluding djustment laims When the Original laim Was lso Excluded When the WF processes an adjustment claim, it shall take the following action when the OF indicates that the production OB trading partner wishes to receive adjustment claims, monetary or adjustment claims, non-monetary: eturn a BO reply trailer 29 to the contractor if WF locates the original claim that was marked with an crossover disposition indicator or if the original claim s crossover disposition indicator was blank/non-existent; Exclude the adjustment claim if WF locates the original claim and it was marked with a crossover disposition indicator other than, meaning that the original claim was excluded from the OB crossover process. WF shall not be required to search archived or purged claims history to determine whether an original claim had been crossed over. The WF maintainer shall create a new crossover disposition indicator, as referenced in a chart within of this chapter, to address this exclusion for customer service purposes. The WF maintainer shall ensure that adjustment claims that were excluded because the original claim was not crossed over shall be marked with an crossover disposition indicator after they have been posted to the appropriate Health nsurance aster ecord (H) detailed history screen.. Excluding Part, B, and D ontractor Fully Paid djustment laims Without Deductible and o-nsurance emaining The WF shall apply logic to exclude Part and Part B (including D) adjustment claims (identified as action code 3 for Part claims and entry code 5 for Part B and D claims) when the OF indicates that a OB trading partner wishes to exclude adjustment claims that are fully paid and without deductible or co-insurance amounts remaining. Effective with October 1, 2007, the WF shall develop logic as follows to exclude fully paid Part adjustment claims without deductible and co-insurance remaining: 1) Verify that the claim contains action code 3 ; 2) Verify that there are no deductible and co-insurance amounts on the claim; 3) Verify that the reimbursement on the claim is greater than zero; and 4) onfirm that the claim contains no denied services or service lines.

17 pecial Note: Effective with October 1, 2007, WF shall cease by-passing the logic to exclude Part adjustments claims fully (100 percent) paid in association with home health prospective payment system (HHPP) types of bills 329 and 339. The WF shall exclude such claims if the OB nsurance File (OF) designates that the trading partner wishes to exclude adjustment claims fully paid without deductible or co-insurance remaining or if these bill types are otherwise excluded on the OB nsurance File (OF). The WF shall develop logic as follows to exclude Part B or D fully paid adjustment claims without deductible or co-insurance remaining: 1) Verify that the claim contains an entry code 5 ; 2) Verify that the allowed amount equals the reimbursement amount; and 3) onfirm that the claim contains no denied services or service lines. The WF maintainer shall create a new crossover disposition indicator for adjustment claims that are paid at 100 percent. The WF maintainer shall ensure that excluded adjustment claims that are paid at 100 percent shall be marked with an crossover disposition indicator after they have been posted to the appropriate H detailed history screen. n addition, the WF maintainer shall add dj. laims-100 percent PD to the OB nsurance File ummary screen (OB) on H so that this exclusion will be appropriately displayed for customer service purposes. laims with Fully Paid Lines, without Deductible or o-insurance emaining, and dditional Denied ervice Lines New HUB Line-Level ndicator Field Effective January 4, 2010, the WF maintainer shall create a new 1-byte LB ND at the service line level for individually denied claim lines in association with the HUB claim transaction (valid values=b or spaces). Part B hared ystem equirements When the Part B shared system adjudicates adjustment claims where most of the claim service detail lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line that are the same as the paid amounts per line and the lines do not carry deductible or co-insurance amounts) but where some detail lines are denied, it shall take the following actions: 1) nput a B value in the newly created 1-byte LB ND field for each denied service line where the beneficiary has payment liability (NOTE: there may be multiple instances where the B value will be applied, contingent upon whether the beneficiary is liable for each of the denied service lines);

18 2) nput spaces in the newly created 1-byte LB ND field for each denied service line where the provider, rather than the beneficiary, is contractually liable for the denied service; and 3) Transmit the HUB claim to WF for normal verification and validation processing. WF equirements The WF system shall modify its logic for adjustment fully paid claims, without deductible or co-insurance remaining, in association with Part B HUB claims as follows: 1) ontinue to verify the claim s entry or action code for confirmation that the claim is an adjustment; 2) Where applicable, also continue to check additionally to determine if the incoming claim contains entry code 5 or an recovery audit contractor () adjustment indicator, as directed in previous instructions; 3) Where applicable, continue to check additionally to determine if the incoming claim contains an entry or action code value of 1, along with laim djustment ndicator=, as per previous direction; 4) onfirm that the claim contains service lines where the amount allowed per line equals the amount paid per line; 5) heck for the presence of a B line LB ND in association with any of the denied service lines on the claim; 6) uppress the claim from the crossover process if the claim does not contain a B line LB ND for any of the denied service lines; and 7) elect the claim for crossover if even one of the denied lines contains a B LB ND. Upon suppressing the Part B claim from the crossover process, WF shall annotate the claim on the Part B claim detail (PTBH) screen with a newly created F (Fully reimbursable claim containing denied lines with no beneficiary liability) claims crossover disposition indicator. (ee of this chapter for more details regarding crossover disposition indicators.) J. Excluding Part, B, and D ontractor djustment laims That re Fully Denied with No dditional Liability The WF shall apply logic to exclude Part and Part B (including D) fully denied adjustment claims that carry no additional beneficiary liability when the OF indicates that a OB trading partner wishes to exclude such claims.

19 Effective with October 1, 2007, the WF shall apply logic to the Part adjustment claim (action code 3 ) where the entire claim is denied and the beneficiary has no additional liability. s of January 4, 2010, that logic shall be changed to also include the reading of action code 8, in addition to action code 3, for HUP and HUOP claims. The revised logic will thus be as follows: 1) Verify that the claim was sent as action code 3 ; 2) Verify also if an HUP or HUOP claim contains action code 8 rather than an action code 3 ; and 3) heck for the presence of an N beneficiary liability indicator in the header of the fully denied claim. (ee the Beneficiary Liability ndicators on Part WF laims Transactions section above for additional information.) The WF shall apply logic to the Part B and D adjustment claims (entry code 5 ) where the entire claim is denied and the beneficiary has no additional liability as follows: 1) Verify that the claim was sent as entry code 5 ; and 2) heck for the presence of an N liability indicator on the fully denied claim. The WF maintainer shall create a new T crossover disposition indicator for adjustment claims that are 100 percent denied with no additional beneficiary liability. The WF maintainer shall ensure that excluded adjustment claims that were entirely denied and contained no beneficiary liability shall be marked with a T crossover disposition indicator after they have been posted to the appropriate H detailed history screen. n addition, the WF maintainer shall add Denied djs-no Liab to the OB on H so that this exclusion will be appropriately displayed for customer service purposes. K. Excluding Part, B, and D ontractor djustment laims That re Fully Denied with No dditional Liability The WF shall apply logic to exclude Part and Part B (including D) fully denied adjustment claims that carry additional beneficiary liability when the OF indicates that a OB trading partner wishes to exclude such claims. Effective with October 1, 2007, the WF shall apply logic to the Part adjustment claim (action code 3 ) where the entire claim is denied and the beneficiary has additional liability. s of January 4, 2010, that logic shall be changed to also include the reading of action code 8, in addition to action code 3, for HUP and HUOP claims. The revised logic will thus be as follows: 1) Verify that the claim was sent as action code 3 ; 2) Verify also if an HUP or HUOP claim contains action code 8 rather than an action code 3 ; and

20 3) heck for the presence of an L beneficiary liability indicator in the header of the fully denied claim. (ee the Beneficiary Liability ndicators on Part WF laims Transactions section above for additional information.) The WF shall apply logic to exclude Part B and D adjustment claims (entry code 5 ) where the entire claim is denied and the beneficiary has additional liability as follows: 1) Verify that the claim was sent as entry code 5 ; and 2) heck for the presence of an L liability indicator on the fully denied claim. The WF maintainer shall create a new U crossover disposition indicator for adjustment claims that are 100 percent denied with additional beneficiary liability. The WF maintainer shall ensure that excluded adjustment claims that were entirely denied and contained beneficiary liability shall be marked with a U crossover disposition indicator after they have been posted to the appropriate H detailed history screen. n addition, the WF maintainer shall add Denied djs-liab to the OB on H so that this exclusion will be appropriately displayed for customer service purposes. L. Excluding P ost-voided laims The WF shall develop logic to exclude P cost-avoided claims when the OF indicates that a OB trading partner wishes to exclude such claims. The WF shall apply the following logic to exclude Part P cost-avoided claims: Verify that the claim contains one of the following P non-pay codes: E, F, G, H, J, K, Q,, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26. The WF shall apply the following logic to exclude Part B and D P cost-avoided claims: Verify that the claim contains one of the following P non-pay codes: E, F, G, H, J, K, Q,, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26. The WF maintainer shall create a new V crossover disposition indicator for the exclusion of P cost-avoided claims. The WF maintainer shall ensure that excluded P cost-avoided claims shall be marked with a V crossover disposition indicator after they have been posted to the appropriate H detailed history screen. n addition, the WF maintainer shall add P ost-voids to the OB on H so that this exclusion will be appropriately displayed for customer service purposes.

21 . Excluding anctioned Provider laims from the OB rossover Process Effective with pril 2, 2007, the WF maintainer shall create space within the HUB claim transaction for a newly developed indicator, which designates sanctioned provider. ontractors, including edicare dministrative ontractors (s), that process Part B claims from physicians (e.g., practitioners and specialists) and suppliers (independent laboratories and ambulance companies) shall set an indicator in the header of a fully denied claim if the physician or supplier that is billing is suspended/sanctioned. NOTE: uch physicians or suppliers will have been identified by the Office of the nspector General (OG) and will have had their edicare billing privileges suspended. Before setting the indicator in the header of a claim, the Part B contractor shall first split the claim it is contains service dates during which the provider is no longer sanctioned. This will ensure that the Part B contractor properly sets the indicator for only those portions of the claim during which the provider is sanctioned. Upon receipt of an HUB claim that contains an indicator, the WF shall exclude the claim from the OB crossover process. The WF therefore shall not return a BO reply trailer 29 to the multi-carrier system () Part B contractor for any HUB claim that contains an indicator. N. Overarching djustment laim Exclusion Logic Overarching adjustment claim logic is defined as the logic that WF will employ, independent of a specific review of claim monetary changes, when a OB trading partner s OB nsurance File (OF) specifies that it wishes to exclude all adjustment claims. New WF Logic Effective with pril 1, 2008, the WF maintainer shall change its systematic logic to accept a new version of the OF that now features a new all adjustment claims exclusion option. For the OB eligibility file-based crossover process, where WF utilizes both the BO auxiliary record and the OF when determining whether it should include or exclude a claim for crossover, WF shall apply the overarching adjustment claim logic as follows: Verify that the incoming claim has an action code of 3 or entry code of 5 or, if the claim has an action or entry code of 1 (original claim), confirm whether it has an claim header value, which designates adjustment claim for crossover purposes; and Verify that the OF contains a marked exclusion for all adjustment claims. f these conditions are met, WF shall exclude the claim for crossover under the OB eligibility file-based crossover process. f both of these conditions are met, WF shall exclude the claim for crossover under the OB eligibility file-based crossover process. POTNT: ndependent of the foregoing requirements, WF shall continue to only select an adjustment claim for OB crossover