(Medicare Claims Processing Manual)

80.3 - Beneficiary Other Insurance Information (HUBO)  Maintenance Transaction Error Codes                                                                                           (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) Effective January 2, 2007, the CWF shall accept and process a HUBO transaction that eithe r updates an existing Beneficiary Other Insurance (BOI) auxiliary record or  adds a new BOI auxiliary record occurrence.   If the CWF receives an incoming HUBO transaction whose COBA identification number (ID) and beneficiary supplemental eligibility -from date (CCYYMMDD) match the equivalent elements within an existing BOI auxiliary record, it shall overlay the existing record with the incoming record.  However, if the CWF receives an incoming HUBO transaction whereby the COBA ID and beneficiary supplemental -from date do not  match the equivalent elements within an existing BOI auxiliary record, it shall create a new BOI auxiliary record occurrence.   For purposes of applying COBA eligibility files to the BOI auxiliary file, the CWF maintainer shall redefine Action Type 0 - Add as 1 -Add/Update.  For purposes of applying COBA eligibility files to the BOI auxiliary record, th e CWF shall now accept and process only two Action Types 1 -  Add/Update and 2  Delete from the BCRC as part of the COBA crossover process.   The CWF shall continue to apply the applicable BO edits that would relate to add/update or delete actions accomplished via the HUBO transaction.  80.4 - Consolidated Claims Crossover Process  (Rev. 11396, Issued:05- 04-2022, Effective:10 -01-2022, Implementation:10- 03-2022)   A.  The Mechanics of the CWF Claims Selection Process and BOI and Claim -based Reply Trailers  1.  CWF Receipt and Processing of the Coordination of Benefits Agreement Insurance File (COIF)   Effective July 6, 2004, the Benefits Coordination & Recovery Center (BCRC)  began to send copies of the Coordination of Benefits Agreement Insurance File (COIF) to the nine CWF host sites on a weekly basis.  The COIF will contain specific information that will identify the beneficiaries other health insurance, also known as the COBA tra ding partner, including name, COBA ID, address, and tax identification number (TIN).  It will also contain each trading partners 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 Medicare Summary Notice (MSN).   The CWF shall load the initial COIF submission from the BCRC  as well as all future weekly updates.   Upon receipt of a claim, the CWF shall take the following actions:  a. Search for a COBA eligibility record on the BOI auxiliary record for each beneficiary, unless there is a COBA ID in range 55000 through 55999 present on the incoming HUBC or HUDC claim (which identifies Medigap claim -based crossover), and obtain the associated COBA ID(s) NOTE:  There may be multiple COBA IDs;   b. Refer to the COIF associated with each COBA ID (NOTE:  CWF shall pull the COBA ID from the BOI auxiliary record) to obtain the COBA trading partners name and claims selection criteria;   c. Apply the COBA trading partners selection criteria; and  d. Trans mit a BOI reply trailer 29 to the A/B MAC or DME MAC  only if the claim is to be sent, via 837 COB flat file or National Council for Prescription Drug Programs (NCPDP) file, to the BCRC  to be crossed over. (See Pub.100-04, Chap. 28, 70.6 for more information about the claim file transmission process involving the A/B MAC or DME MAC  and the BCRC .)  Effective with the October 2004 systems release, CWF shall read the COIF submission to determine whether a Test/Production Indicator T (test mode) or P (production mode) is present.  CWF will then include the Test/Production Indicator on the BOI reply trailer 29 that is returned to the A/B MAC or DME MAC .  (See additional details below.)  Effective with July 7, 2009, at CMSs direction, the BCRC  modified  the CO IF so that the Test/Production indicator, originally created as part of the October 2004 release, is renamed the 4010A1 Test/Production indicator and a new field, the NCPDP-5.1 Test/Production indicator, is also reflected.  In turn, CWF shall 1) accept and process the BCRC -generated modified COIF on a weekly basis; and 2) accept the following values within the two newly defined COIF fields:  N (format not in use for this trading partner); P (trading partner in production); and T (trading partner in test mode). CWF shall also modify the BOI reply trailer (29) to reflect these changes, as further specified under BOI Reply Trailer 29 Processes below.   2.  BOI Reply Trailer 29 Processes  For purposes of eligibility file-based crossover, if CWF se lects a claim for crossover, it shall return a BOI reply trailer 29 to the  A/B MAC or DME MAC.  The returned BOI reply trailer 29 shall include, in addition to COBA ID(s), the COBA trading partner name(s), an A 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 COBA trading partners name should be printed on the beneficiary MSN.  Effective with the October 2004 systems release, CWF shall also include a 1- digit Test/Production Indicator T (test mode) or P (production mode) on the BOI reply trailer 29 that is returned to the A/B MAC or DME MAC.   Effective with July 7, 2009, CWF shall modify the BOI reply trailer (29) to rename the existing Test/Production indicator as 4010A1 Test/Production indicator and rename the NCPDP Test/Production indicator as NCPDPD0 Test/Production indicator.  In addition, CWF shall include a new 1 -byte field NCPDP51 Test/Production indicator as part of the BOI reply trailer (29).   B.  MSN Crossover Messages   Beginning with the October 2004 systems release, when a n A/B MAC  or DME MAC receives a BOI reply trailer 29 from CWF that contains a Test/Production Indicator T (test mode), it shall ignore the MSN Indicator provided on the trailer.  Instead, the A/B MAC  or DME MAC shall follow its existing procedures for inclusion of trading partner names on MSNs for those trading partners with whom it has existing Trading Partner Agreements (TPAs).   Beginning with the October 2004 systems release, when a n A/B MAC or DME MAC  receives a BOI reply trailer 29 from CWF that contains a Test/Production Indicator P (production mode), it shall read the MSN indicator (Y=Yes, print trading partners name; N=Do not print trading partners name) returned on the BOI reply trailer 29.  (Refer to Pub.100- 4, chapter 28, 70.6 for additional details.)   Effective January 5, 2009, when CWF returns a BOI reply trailer (29) to a n A/B MAC  or DME MAC  that contains only a COBA ID in the range 89000 through 89999, the shared system shall suppress all crossover information, including name of insurer and generic message#35.1, from all beneficiary MSNs.  (See chapter 28, 70.6 for details regarding additio nal A/B MAC and DME MAC  requirements.)   In addition, the A/B MAC or DME MAC  shall not issue special provider notification letters following its  receipt of BCRC  Detailed Error Reports when the claims associated COBA ID is within the range 89000 through 89999 (see chapter 28, 70.6.1 for more details.)   C.  Electronic Remittance Advice (835)/Provider Remittance Advice Crossover Messages   Beginning with the Octobe r 2004 release, when CWF returns a BOI reply trailer (29) that contains a T Test/Production Indicator to the A/B MACs and DME MACs , they shall not print information received from the BOI reply trailer (29) in the required crossover fields on the 835 Elec tronic Remittance Advice or other provider remittance advice(s) that is/are in production.  A/B MACs  and DME MACs shall, however, populate the 835 ERA (or provider remittance advice(s) in production) with required crossover information when they have exist ing agreements with trading partners.   Beginning with the October 2004 release, when CWF returns a BOI reply trailer (29) that contains a P Test/Production Indicator to the A/B MACs and DME MACs , they shall use the returned BOI trailer information to tak e the following actions on the providers 835 Electronic Remittance Advice:   1.  Record code 19 in CLP -02 (Claim Status Code) in Loop 2100 (Claim Payment Information) of the 835 ERA (v. 4010- A1). [NOTE:  Record 20 in CLP -02 (Claim Status Code) in Loop 2100 (Claim Payment Information) when Medicare is the secondary payer.]   2.  Update the 2100 Loop (Crossover Carrier Name) on the 835 ERA as follows:    NM101 [Entity Identifier Code] Use TT, as specified in the 835 Implementation Guide.    NM102 [Entity Type Qualifier] Use 2, as specified in the 835 Implementation Guide.   NM103 [Name, Last or Organization Name] Use the COBA trading partners name that accompanies the first sorted COBA ID returned to you on the BOI reply trailer.    NM108 [Identification Code Qualifier] Use PI (Payer Identification.)    NM109 [Identification Code] Use the first COBA ID returned to you on the BOI reply trailer.  (See line 24 of the BOI aux. file record.   If the 835 ERA is not in production and the A/B MAC or  DME MAC  receives a P Test/Production Indicator, the A/B MAC  or DME MAC  shall use the information provided on the BOI reply trailer (29) to populate the existing provider remittance advices that it has in production.  Effective January 5, 2009, if CWF re turns only a COBA ID range 89000 through 89999 on a BOI reply trailer (29) to a n A/B MAC or DME MAC , the associated shared system shall suppress all crossover information (the entire 2100 loop) on the 835 ERA.  Effective October 3, 2011, when a beneficiarys claim is associated with more than one COBA ID (i.e., the beneficiary has more than one health insurer/benefit plan tha t has signed a national COBA), CWF shall sort the COBA IDs and trading partner names in the following order:   1)  Eligibility -based Medigap (30000- 54999); 2) Claim -based Medigap (55000- 59999); 3) Supplemental (00001- 29999); 4) Other Insurer (80000- 80213); 5) Other Insurer (80215 -88999); 6) CHAMPVA (80214); 7) TRICARE (60000- 69999); 8) Medicaid (70000-79999); and 9) Other Health Care Pre -Payment Plan [HCPP] (89000- 89999).  When two or more COBA IDs fall in the same range (see item 24 in the BOI Auxiliary File table above), CWF shall sort numerically within the same range.   3.  CWF Treatment of Non- assigned Medicaid Claims