(Medicare Claims Processing Manual)

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.   6. When the shared system determines that it has data within its internal provider file to populate 2010AA PER 04, it shall only move that information to the corresponding flat file field if the available data are complete.  If the available data are incomplete (i.e., fewer than 10 digits for telephone number), the shared system shall no t attempt to gap- fill the missing digits.  The shared system shall also not create that PER segment.   7. With respect to 2010BA N301 and 2330A N301, when the A/B MAC (B) or DME MACs internal beneficiary eligibility record contains blank or incomplete line-1 street address information, FISS shall apply Xs to satisfy the minimum length requirements of the N301 segments.     8. If the incoming claim is paper Form CMS -1450 or DDE- entered and the dosage information necessary to populate 2410 CTP05-1 is not available, FISS shall always default to the value of F2.  9. If the incoming claim is paper or electronic, FISS shall map non- specific procedure code within the ASC X12 837 new version COB flat file field that corresponds to loop 2400 SV202-7 (non- specific composite medical procedure description) if a non -specific procedure code description is required, as per the Implementation Guide, and the associated procedure code is defined as not otherwise classified.  (See the following link for the latest listing of not otherwise classified procedure codes: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha- Numeric -HCPCS.html?DLSort=0&DLEntries=10&DLPa ge=1&DLSortDir=descending&DLFilter=NOC   10. FISS shall not attempt to gap -fill or systems -fill the N4 segment (now situational) within the field corresponding to loop 2330B on the ASC X12 837 new version COB flat file.  I n addition, if information needed to create the N4 segment is available but is incomplete, FISS shall not create the loop 2330B N4 segment.   11. FISS shall not attempt to gap -fill or systems -fill any of the composite SVD03 elements within loop 2430.  B. ASC X12  837 Professional COB Claims  1. For all instances of the N403 segment, where created, the A/B MAC ( B) and DME MAC shared systems shall ensure that it creates a 5 -byte base ZIP code and additional 4-byte component for the COB flat file when required.  2. The A/B MAC (B) and DME MAC shared systems shall universally gap- fill or system -fill required individual address elements, when not otherwise obtainable, for all Subsc riber-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 otherwise  not unavailabl e.  3. The A/B MAC (B) and DME MAC shared systems 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), 2310C (Service Facility claim level), and 2420C (Service Facilityservice line level).  (NOTE:   The full 9-byte ZIP code is required only for the N403 segment of the indicated loops.)  4. The A/B MAC (B) and DME MAC shared systems 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 A/B MAC (B) and DME MAC shared systems have valid city, state, and 5-byte ZIP code  information available, they 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 A/B MAC (B) and DME MAC 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 N403segments   6. When the shared system determines that it has data within its internal provider file to populate 2010AA PER 04, it shall only move that information to the corresponding flat file field if the available data are complete.  If the available data are incomplete (i.e., fewer than 10 digits for telephone number), the shared system shall not attempt to gap- fill the equivalent field on the new version COB flat file.    7. With respect to 2010BA N301 and 2330A N301, when the A/B MAC (B) or DME MACs internal beneficiary eligibility record contains blank or incomplete line-1 street address information, the shared system shall apply Xs to satisfy the minimum length requirements of the N301 segments.  8a. In association with paper- submitted Part B ambu lance claims, the A/B MAC (B) shared system shall apply gap-filling to the N3 and N4 portions of loop 2310E and 2310F as follows for the segments indicated:   For N301:   The A/B MAC (B) shared system shall map Xs to the minimum  standard required for the field.    For N401N403:  The A/B MAC (B) shared system shall undertake the following actions:   N401 (City)populate Cityville;  N402 (State Code)populate MD; and  N403 (Postal Zone/ZIP Code)populate 96941.  8b. In addition, the A/B MAC (B) shared system shall gap-fill the required +4 component of ZIP code (N403 segment) with 9998 only in association with loops 2010AA, 2310C, and 2420C.  9. The shared system shall map UN in the ASC X12 837 new version COB flat f ile field that corresponds to loop 2410 (CTP) and segment CPT04 only when the 2410 (CTP) CTP04 segment is either blank or contains a non-valid value.  10. The shared system shall apply the gap-fill value X to the field corresponding to loop 2430 (SVD) and segment SVD03-2 in situations where the value on the incoming claim is either missing or non -valid.  11. The A/B MAC (B) shared system shall discontinue the process of gap- filling diagnosis code information within loop 2300 HI in association with ambulance claims that ambulance suppliers file to Medicare on paper.   12a. Following adjudication of both electronic and paper billed claims, the shared system shall discontinue the practice of applying gap- fill values of all 9s within the ASC X12 837 new version COB flat file field that corresponds to 2410 LIN03 if the incoming claim contains an incomplete or non-valid national drug code (NDC).  If an incoming paper claim contains a syntactically non- valid NDC code that the A/B MAC (B) or DME MAC subsequently keys, the shared system shall not attempt to gap -fill the field that corresponds to 2410 LIN03 on the ASC X12 837 new version COB flat file.    12b. The DME MAC shared system shall gap -fill the loop 2430 (SVD) SVD03-2 segment with S5000 or S5001, as appropriate, in situations where the incoming claim contains an NDC within the 2410 LIN02 that does not correspond to a HCPCS on the NDC/HCPCS crosswalk.   13. If the incoming claim is paper and A/B MAC or DME MACs internal provider file contains incomplete information necessary to populate the 2310C loop (in cases where required), the shared system shall gap- fill all required segments with Xs.  NOTE:  The shared system shall discontinue the practice of mapping submitted but not forwarded as a gap -fill convention in this situation for segments where information is required.  14.  If the incoming claim is paper or electronic, the shared system  shall map non-specific procedure code within the ASC X12 837 COB flat file field that corresponds to loop 2400 SV202-7 (non- specific composite medical procedure description) if a non- specific procedure code description is required, as per the Implementation G uide, and the associated procedure code is defined as not otherwise classified.  (See the following link for the latest listing of not otherwise classified procedure codes: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha- Numeric -HCPCS.html?DLSort=0&DLEntr ies=10&DLPage=1&DLSortDir=descending&DLFilter=NOC    15. The A/B MAC (B) shared system shall utilize the claims earliest service date to satisfy the requirement for 2300 DTP03 (date of admission), where required, in association with claims whose place of service code is 21, 51, or 61.  16. The A/B MAC (B) shared system shall populate 99 as a gap- fill/default value for loop 2300 (CLM) segment CLM05-1 (Facility Type Code) within the corresponding field of the ASC X12 837 ne w version COB flat file.   17. For ambulance claims, the A/B MAC (B) shared system shall map LB in the ASC X12 837 new version COB flat file field the corresponds to 2400 CR101 if that field would otherwise contain spaces where there is a value (weight) present in 2400 CR102.  18. Also, for ambulance claims, the A/B MAC (B) shared system shall produce spaces in the field that corresponds to loop 2400 CR101 when loop 2400 CR102 on the incoming claim is blank.   19. All shared systems shall not attempt to gap -fill or systems -fill the N4 segment (now situational) within the field corresponding to loop 2330B on the ASC X12 837 COB flat file.  In addition, if information needed to create the N4 segment is available but is incomplete, the shared systems shall not create the loop 2330B N4 segment.  IV. Other ASC X12 837 New Version COB Requirements    A. Complementary Credits   Upon receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) that contains a P ASC X12 837 indicator, the shared systems shall ensure that their affiliate A/B MACs and DME MACs are able to:  1) book complementary credits for the affected claim; and 2) transmit the production claim to the BCRC after it has finalized on the A/B MAC or DME MACs payment floor.  Following receipt of a BOI reply trailer (29) that contains a T ASC X12 837  indicator, as applicable, the shared systems shall ensure that their affiliate MACs:  1) do not anticipate receipt of complementary credits for that version of the claim; and 2) transmit the test claim to the BCRC after it has finalized on the contractors payment floor.   All shared systems shall, in addition, not expect complementary credits in association with their affiliated A/B MAC or DME MACs receipt of a CWF BOI reply trailer (29) that con tains an N new version indicator.  B. BCRC Business- Level Editing of Incoming New Version COB Flat Files