(Medicare Claims Processing Manual)

The OCE detects inconsistencies between a patients age and any diagnosis on the patients record.   5. Sex Conflict  The OCE detects inconsistencies between  a patients sex and a diagnosis or procedure on the patients bill.  6. Questionable Covered Procedures   These are procedures that may be covered, depending upon the medical circumstances.  For example, HCPCS code 19360 Breast reconstruction with muscle or myocutaneous flap is a condition that is not covered when performed for cosmetic purposes.  However, if this procedure is performed as a follow -up to a radical mastectomy, it is covered.   7. Noncovered Procedures   These are procedures that are not payable.  The A/B MAC (A) denies the bill.  8. Medicare as Secondary Payer -  MSP Alert (versions V1.0 and V1.1 only)   Diagnoses codes that identify situations that may involve automobile medical, no- fault or liability insurance.  The provider must determine the availability of other insurance coverage before billing Medicare.   9. Invalid Age   If the age reported is not between 0 years and 124 years, the OCE assumes the age is in error.   If the beneficiarys age is established at over 124, enter with 123.   10. Invalid Sex   The sex code reported must be either 1 (male) or 2 (female).  Usually, the A/B MAC (A) can resolve the issue.   11.  Date Range   This edit is used in internal A/B MAC (A) operations.   12. Valid Date   The OCE checks the month, day, and year from  FL 6 (from date). If the date is impossible, the A/B MAC (A) returns the bill.   13. Unlisted Procedures   These are codes for surgical procedures (i.e., codes generally ending in 99).   40.4 - Paying Claims Outside of the IOCE  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  All institutional outpatient claims are routed through the IOCE before they are processed to payment.  There may be special circumstances, however, when it is necessary to pay claims bypassing IOCE edits.  The CM S will notify the contractor of these instances.  They include:    New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes timely; and    Errors are discovered that cannot be corrected timely.   A/B MACs (A) are responsible for reporting problems timely.   40.4.1 - Requesting to Pay Claims Without IOCE Approval  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  The contractor may also request approval from the RO in specific situation s to pay claims without first sending them through the IOCE.  Examples of such situations are:    A systems error cannot be corrected timely, and the provider's cash flow will be substantially impacted; and/or    Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside the normal process.   40.4.2 - Procedures for Paying Claims Without Passing through the IOCE  (Rev. 4233, Issued: 02- 08-19, Effective: 03- 12-19, Implementation: 03 -12-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim N umber (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Before an outpatient claim may be paid without first going through the IOCE, the contractor shall obtain approval from CMS Central Office or the RO.  In all instances involving payment outside the normal outpatient editing process, the contractor applies the following procedures:    Contractors shall subm it the claim overriding the IOCE using the appropriate field in FISS.    Pay interest accrued through the date payment is made on clean claims. Do not pay any additional interest.     Maintain a record of payment and implement controls to be sure that incorrect  payment is not made, i.e., when the claim is paid without being subject to normal editing.    Monitor IOCE software to determine when the impediment to processing is removed.    Consider the claim processed for workload and expenditure reports when it is paid.   Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a monthly report of all outpatient claims paid without processing through the IOCE.  The list of claims paid outside of the IOCE is to include the following information:   o Mbi o DCN o TOB  o DOS (From/Through)  o Provider Number  o MCE/OCE OVR (Claim/Line)  o Reimbursement Amount  o Receipt Date  o Process Date  o Paid Date   Also, include summary data for each edit code showing claim volume and payment.  Any override approvals received and/or relev ant JSM references should be annotated on the reports.    40.5 - Transitional Pass-Throughs for Designated Drugs or Biologicals  (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  Certain current designated drugs and biologicals are assigned to special APCs.  I/OCE identifies these and assigns the appropriate APC.  Fiscal Intermediary Shared System (FISS) establishes payment at the average sales price (ASP) drug fee amount minus the  portion of the otherwise applicable APC payment amount.  I/OCE and FISS will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.   All related payment calculations will be returned by the I/OCE and F ISS, identified as a designated drug and biological with status indicator (SI) K.  Certain new designated drugs and biologicals may be approved for payment, and their payment will be calculated in the same manner as listed above for current designated dr ugs and biologicals.  IOCE identifies these new designated drugs and biologicals (SI G) separately from the current designated drugs and biologicals (SI K).  Note:   See section 40.1 for the I/OCE instructions and specifications   50 - Outpatient Pricer (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  Outpatient Pricer determines the amount to pay as well as deductions for deductible and coinsurance.   This CMS -developed software is updated on a quarterly basis to determine the APC line item price (as well as applicable coinsurance/deductible) based on data from the Outpatient Provider Specific File (OPSF), the beneficiary deductible record and the OCE output file.  Pricer prepares an output data record with the following inf ormation:    All information passed from the OCE;    The APC line item payment amount;   The APC line item deductible;   The APC line item coinsurance amount;    The total cash deductible applied to the OPPS services on the claim;    The total blood deductible applied to the OPPS services on the claim;    The APC line item blood deductible;    The total outlier amount for the claim to be paid in addition to the line item APC payments.  This amount is to be reported to CWF via value code 17 as is the process for inpatient outlier payments; and   A Pricer assigned review code to indicate why or how Pricer rejected or paid the claim.   The Pricer implementation guide has information concerning Pricer processing reports, input parameters, and data requirements.   50.1 - Outpatient Provider Specific File  (Rev. 10121, Issued: 05-08-2020, Effective: 10-01- 2020, Implementation: 10-05-2020)    The Outpatient Provider Specific File (OPSF) contains the required information about each provider to enable the pricing software to calculate the payment amount. Data elements and formats are shown below. Contractors must maintain the accuracy of the data , and update the file as changes occur in data element values, e.g., changes in metropolitan statistical area (MSA), bed size, cost to charge ratio. An update is accomplished by preparing and adding an additional complete record showing new current values and the effective date of the change. The old record is retained without change.    Contractors must also furnish CMS a quarterly file in the same format.     NOTE : All data elements, whether required or optional, must have a default value of 0 (zero) if  numerical, or blank if alphanumerical.    File Position     Format    Title     Description   1-10   X(10)   National Provider Identifier (NPI)   Alpha -numeric 10 character provider number.   11-16   X(6)   Provider Oscar Number   Alpha -numeric 6 character provider number.   17-24   9(8)   Effective Date   Must be numeric, CCYYMMDD. This is the effective date of the provider's first OPPS period. For subsequent OPPS periods, the effective date is the date of a change to the PROV fil e. If a termination date is present for this record, the effective date must be equal to or less than the termination date.     25-32   9(8)   Fiscal Year  Beginning Date   Must be numeric, CCYYMMDD.   Month: 01-12   Day: 01 -31   The date must be greater than 19990630.     33-40   9(8)   Report Date   Must be numeric, CCYYMMDD.   Month: 01-12   Day: 01 -31   The created/run date of the PROV report for submittal to CO.      41-48   9(8)   Termination Date   Must be numeric, CCYYMMDD. Must be zeroes or contain a termination date. (Once the official tie-out notice from CMS is received). Must be equal to or greater than the effective date. (Termination date is the date on which the reporting contractor ceased servicing the provider in question).    49   X(1)   Waiver Indicator   Enter a Y or N.   Y = waived (provider is not under OPPS)         For End Stage Renal Disease (ESRD) facilities provider waived blended payment, pay full PPS.   N = not waived (provider is under OPPS)        For ESRD facilities provider did not waive blended payment. Pay according to transitional payment method for ESRD PPS through 2013.     50-54   9(5)   Intermediary Number   Enter the Contractor #.    55-56   X(2)   Provider Type   This identifies providers that require special handling. Enter one of the following codes as appropriate.     00 or blanks = Short Term Facility   02 Long Term   03 Psychiatric   04 Rehabilitation Facility   05 Pediatric   06 Hospital Distinct Parts        (Provider type 06 is effective until July 1, 2006. At that point, provider type 06 will no longer be used. Instead, contractors will assign a hospital distinct part as one of the following provider types: 49, 50, 51, 52, 53, or 54)   07 Rural Referral Center   08 Indian Health Service   13 Cancer Facility   14 Medicare Dependent Hospital (during cost reporting periods that began on or after April 1, 1990.   15 Medicare Dependent Hospital/Referral Center (during cost reporting periods tha t began on or after April 1, 1990. Invalid October 1, 1994 through September 30, 1997).   16 Re-based Sole Community Hospital   17 Re-based Sole Community Hospital /Referral Center   18 Medical Assistance Facility  21 Essential Access Community Hospital   22 Essential Access Community Hospital/Referral Center   23 Rural Primary Care Hospital   32 Nursing Home Case Mix Quality Demonstration Project  Phase II   33 Nursing Home Case Mix Quality  Demonstration Project  Phase III  Step 1  34 Reserved   35 Hospice   36 Home Health Agency   37 Critical Access Hospital        38 Skilled Nursing Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998   40 Hospital Based ESRD Facility   41 Independent ESRD Facility   42 Federally Qualified Health Centers   43 Religious Non-Medical Health Care Institutions   44 Rural Health Clinics-Free Standing   45 Rural Health Clinics-Provider Based   46 Comprehensive Outpatient Rehab Facilities   47 Community Mental Health Centers   48 Outpatient Physic al Therapy Services   49 Psychiatric Distinct Part   50 Rehabilitation Distinct Part   51 Short-Term Hospital  Swing Bed   52 Long -Term Care Hospital  Swing Bed   53 Rehabilitation Facility  Swing Bed   54 Critical Access Hospital  Swing Bed    57  X(1)  Special Locality Indicator  Indicates the type of special locality provision that applies.