(Medicare Claims Processing Manual)

S PECIAL NOTE:  I f, for example, a claim contains at least two (2) primary payers before Medicare, the DME MAC shared system shall reflect the primary payer as 2320 SBR01as P; the secondary payer as 2320 SBR01 = S; and, the tertiary payer, Medicare, as 2320 SBR01 = T.  MCS shall reflect all additional supplemental payers as 2320 SBR01 = U.  10b. For 2000B SBR01 (element 1138), the shared system shall apply P when Medicare is the primary payer and shall apply U for all other supplemental payers after Medicare.   11. For additional 2000B requirements, the shared system shall take the following actions:   a. SBR03 map spaces; and  b. SBR09 If the COBA ID returned via the BOI reply trailer (29)=70000-79999, map MC; for all other COBA IDs, map  CI.  12. The 2010BA loop denotes beneficiary subscriber information.  There are two (2) crossover scenarios to address:  regular, eligibility file -based crossover, and Medigap claim -based crossover.    (1)  For regular eligibility file -based crossover (COBA ID=anything except 55000 through 59999), the shared system shall populate the NM1, N3, and N4 segments as follows:    2010BA NM1Subscriber Name:   a. NM101popula te IL;  b. NM102populate 1; c. NM103derive from internal beneficiary eligibility file; d. NM104derive from internal beneficiary eligibility file; e. NM105derive from internal beneficiary eligibility file if available;    otherwise populate spaces;  f. NM108populate MI; and  g. NM109populate the beneficiarys Medicare beneficiary identifier .  2010BA  N3Subscriber Address:   a. N301derive from internal beneficiary eligibility file; and  b. N302derive, as necessary, from internal beneficiary  eligibility file; otherwise populate spaces.  2010BA N4Subscriber City/State/ZIP Code:   a. N401derive from internal beneficiary eligibility file; b. N402derive from internal beneficiary eligibility file;  c. N403derive from internal beneficiary eligibi lity file; and  d. N407derive if available and applicable from internal beneficiary eligibility file; otherwise populate spaces.  NOTE :   See G ap-Fill section for the valu es to be  populated on outbound C OBA crosso ver claims when the individual data conte nt for N401 (City) or N402 ( State) or N403(Zip/Postal Code) cannot othe rwise  be d erived.    (2) Medigap claim -based crossover (COBA ID=55000 through 59999 only), the shared system shall populate the NM1, N3, and N4 segments as follows:    2010BA NM1Subscriber Name:   a. NM101populate IL; b. NM102populate 1; c. NM103derive from internal beneficiary eligibility file; d. NM104derive from internal beneficiary eligibility file; e. NM105derive from internal beneficiary eligibility file if  available; otherwise populate spaces; f. M108populate MI; and g. M109populate beneficiary policy number as derived from Item 9- D of Form CMS -1500 claim or 2330B NM109 of the incoming 837 professional claim.  The shared system shall only populate the beneficiarys Medicare beneficiary identifier here if the policy number is unavailable on the incoming claim.   2010BA N3Subscriber Address:   a. N301derive from internal beneficiary eligibility file; b. N302derive, as necessary, from internal beneficiary eligibility file; otherwise populate spaces.   2010BA N4Subscriber City/State/ZIP Code:   a. N401derive from internal beneficiary eligibility file; b N402derive from internal beneficiary eligibility file; c. N403derive from internal benefici ary eligibility file; and  d. N407derive, if available, from internal beneficiary eligibility file; otherwise populate spaces. NOTE :   See G ap-Fill section for the valu es to be  populated on outbound C OBA crosso ver claims when the individual data conte nt for N401 (City) or N402 ( State) or N403 (Zip/Postal Code) cannot othe rwise  be d erived.   13. The shared system shall populate the 2330A (Other Subscriber) NM1, N3, and N4 segments as follows:     2330ANM1:    a. NM101populate IL; b. NM102populate 1; c. NM103derive from internal beneficiary eligibility file; d. NM104derive from internal beneficiary eligibility file; e. NM105derive from internal beneficiary eligibility file if available; otherwise populate spaces; f. NM108populate MI; and  g. NM109populate the beneficiarys Medicare beneficiary identifier.    2330A- N3:  a. N301derive from internal beneficiary eligibility file; and  b. N302derive, as necessary, from internal beneficiary eligibility file as necessary; otherwise populate spaces.    2330A- N4:  Upon implementation of the 5010 Errata, the A/B MAC  (B) and DME MAC shared systems shall not attempt to gap -fill or systems -fill any elements (N401 N407) within this segment.  Also, if these elements are available but are incomplete, the shared systems shall not create the N4 segment tied to loop 2330A within the ASC X12 837 COB flat file.  a. N401derive from internal beneficiary eligibility file; and  b. N402, N403, N404, N407derive from internal beneficiary eligibility file if available and applicable; otherwise populate spaces.   14. The 2010BB loop denotes the payer name.  Per the HIPAA Implementation Guide, this loop should define the secondary payer when sending the claim to the second destination payer.  Thus, since the payer related to the COBA ID w ill be unknown by the shared systems, the shared system shall format the NM1, N3, and N4 segments as follows, with the BCRC completing any missing information:   2010BBNM1:   a. NM101populate PR;  b. NM102populate 2; c. NM103populate spaces; d. NM108populate PI; and  e. NM109populate the COBA ID (5 digit COBA ID as obtained from the BOI reply trailer 29).    2010BB-N3 & 2010BB- N4:  a. N301 & N302populate spaces; and  b. For N401, N402, N403, N404, N407, populate spaces.  15. The shared system s hall not  create the 2000C or the 2010CA loops within the ASC X12 837 new version professional COB flat file.  16. If the shared system notes the presence of other payers within 2320 SBR and 2330B loops that had made no financial determination on a claim prior to Medicare, as in the case of Medicare secondary payer (MSP) situations, the shared system shall not move those loops to the ASC X12 837 new version COB professional flat file.   17. The 2330B loop denotes other payers for the claim following Medicare.  There will always be one (1) 2330B that denotes Medicare as a payer, with the shared system completing all required information for NM101, NM102, NM103, NM108, NM109, as well as the N3 and N4 segments.  18. For additional 2330B loop iterations relating to COB, if the A/B MAC (B) or DME MAC receives multiple COBA IDs via the BOI reply trailer (29), payer information for additional COBA IDs will be unknown.  As with the 2010BB loop, the shared system shall format the NM1 segment as follows, with the  BCRC completing missing information:   2nd and additional iterations of 2330BNM1:   a. NM101populate PR;  b. NM102popula te 2;  c. NM103populate spaces; d. NM108populate PI; and  e. NM109populate the COBA ID (5 digit COBA ID as obtained from the BOI reply trailer 29).    2nd and additional iterations of 2330B-N3 & 2330B- N4:  a. N301 & N302populate spaces; and b. For N401, N402, N403, N404, N407, populate spaces.  19. The shared system shall always send at least one (1) complete iteration of 2320, 2330A, and 2330B on all ASC X12 837 COB flat files.  20. For 2300 REF (4081-Mandatory Crossover Indicator), the shared syst em shall take the action indicated below in accordance with the applicable scenario:   a. REF01, always map F5;   b. REF02, map Y if the COBA ID returned via the BOI reply trailer (29)=55000 through 55999 (Medigap claim- based crossover); and    c. REF02, map N if the COBA ID returned via the BOI reply trailer (29) =anything except for 55000 through 55999 (regular crossover).  Additional Mapping Requirements When Incoming Claim is Paper/Hard- Copy   **IMPORTANT:  The shared system shall create an outbound new version skinny claim, as derived from paper/hard copy claim input, in the same manner that it now does in creating the current in- use (prior to new version) claim, unless otherwise specified above or below.  1. The shared system shall always  map NDC codes keye d from hard -copy claims to the field that corresponds to 2410 LIN03 on the ASC X12 837 new version COB professional flat file.  In addition, the shared system shall auto-plug the appropriate qualifier that designated NDC within the field that corresponds to 2410 LIN02.    2. If the incoming paper claim contains an NPI in block 32 of the Form CMS-1500, the shared system shall continue to utilize this keyed value for purposes of deriving the information necessary to populate all required segments associated with 2310C (Service Facility Name).  The shared system shall continue to not create the 2310C loop if block 32 on the incoming paper claim is blank.  3. If the incoming claim is paper and does not contain information necessary to derive 2410 CTP5-1 (in association with Part B drugs), the shared system shall auto-plug the value F2.  III. Gap- Filling Requirements for ASC X12 837 New Version COB Files (Effective July 2012)  A. ASC X12  837 Institutional COB Claims  1. For all instances of the N403 segment, where created, FISS shall ensure that it creates a 5-byte base ZIP code and additional 4-byte component for the COB flat file when required.  2. FISS shall universally gap- fill or systems -fill required individual address elements, when not otherwise obtainable, for Subscriber-related loops as follows:  N401 (City Name) = Cityville;  N402 (State or Province Code) = MD; and  N403 (Postal Zone/ZIP Code) = 96941.  NOTE :   The  above is partic ularly  applic able in the creation of the indic ated segme nts within the 2010BA loop when the neede d data are individua lly not otherwise  unavailabl e.   3. FISS shall gap -fill the +4 ZIP code component with 9998 when the actual +4 ZIP code component is unavailable when creating the N403 in association with loops 2010AA (Billing Provider) and 2310E (Service Facility).  ( NOTE:   The full 9-byte ZIP code is required only for the N403 segment of the indicated loops.)  4. FISS shall never input 0000 as a gap- fill or system-fill +4 ZIP code in association with any of the N403 segments.  5a. If the shared system has valid city, state, and 5-byte ZIP code information available, it shall only gap- fill or system-fill the +4 ZIP code component, where required, with 9998 when creating outbound ASC X12 837 COB claim files.  5b. The shared system shall continue to send full ZIP code content (9-bytes) on outbound ASC X12 837 COB claim files, if available, for creation of situational N403 segments.