(Medicare Claims Processing Manual)

1) Verify that the claim was sent as action code 3;   2) Verify also if an HUIP or HUOP claim contains action code 8 rather than an action code 3; and   3) Check for the presence of an L beneficiary liability indicator in the header of the fully denied claim. (See the Beneficiary Liability Indicators on Part A CWF Claims Transactions section above for additional information.)   The CWF shall apply logic to exclude Part B and DM EPOS  adjustment claims (e ntry 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) Check for the presence of an L liability indicator on the fully denied claim.  The CWF maintainer shall create a new U crossover disposition indicator for adjustment claims that are 100 percent denied with additional beneficiary liability.  The CWF 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 HIMR detailed history screen.  In addition, the CWF maintainer shall add Denied Adjs-Liab to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  L.  Excluding MSP Cost-Avoided Claims  The CWF shall develop logic to exclude MSP cost -avoided claims when the COIF indicates that a COBA trading partner wishes to exclude such claims.   The CWF shall apply the following logic to exclude Part A MSP cost -avoided claims:    Verify that the claim contains one of the following MSP non- pay codes:  E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26.  The CWF shall apply the following logic to exclude Part B and DMAC MSP cost -avoided claims:    Verify that the claim contains one of the following MSP non- pay codes:  E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26.  The CWF maintainer shall create a new V crossover disposition indicator for the exclusion of MSP cost -avoided claims.  The CWF maintainer shall ensure that excluded MSP cost -avoided claims shall be marked with a V crossover disposition indic ator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add MSP Cost -Avoids to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.   M.  Ex cluding Sanctioned Provider Claims from the COBA Crossover Process   Effective with April 2, 2007, the CWF maintainer create d space within the HUBC claim transaction for a newly developed S indicator, which designates sanctioned provider.   A/B MACs (B) that process claims from physicians (e.g., practitioners and specialists) and suppliers (independent laboratories and ambulance companies) shall set an S indicator in the header of a fully denied claim if the physician or supplier that is billing is suspended/sanctioned.  NOTE:  Such physicians or suppliers will have been identified by the Office of the Inspector General (OIG) and will have had their Medicare billing privileges suspended.  Before setting the S indicator in the header of a claim, the  A/B MAC (B) shall first split the claim it is contains service dates during which the provider is no longer sanctioned.  This will ensure that the A/B MAC (B) properly sets the S indicator for only those portions of the claim during which the provider i s sanctioned.   Upon receipt of an HUBC claim that contains an S indicator, the CWF shall exclude the claim from the COBA crossover process.  The CWF therefore shall not return a BOI reply trailer 29 to the A/B  MAC (B) for any HUBC claim that contains an S indicator.   N.  Overarching Adjustment Claim Exclusion Logic   Overarching adjustment claim logic is defined as the logic that CWF will employ, independent of a specific review of claim monetary changes, when a COBA trading partners COIF specifies th at it wishes to exclude all adjustment claims.   Modified  CWF Logic  Effective with April 1, 2008, the CWF maintainer shall change its systematic logic to accept a new version of the COIF that now features a new all adjustment claims exclusion option.  For the COBA eligibility file -based crossover process, where CWF utilizes both the BOI auxiliary record and the COIF when determining whether it should include or exclude a claim for crossover, CWF shall apply the overarching adjustment claim logic as follow s:   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 A claim header value, which designates adjustment claim for crossover purposes; and   Verify that the COIF contains a marked exclusion for all adjustment claims.  If these conditions are met, CWF shall exclude the claim for crossover under the COBA eligibility file -based crossover process.  If both of these conditions are met, CWF shall exclude the claim for crossover under the COBA eligibility file -based crossover process.  IMPORTANT:   Independent of the foregoing requirements, CWF shall continue to only select an adjustment claim for COBA crossover purposes if :  1) it locates the matching original claim; and 2) it determines that the original claim was selected for crossover (see H.  Excluding Adjustment Claims When the Original Claim Was Also Excluded above for more information).  New Crossover Disposition Indicator   Upon excluding the claim, CWF shall mark the claim as it is stored on the appropriate HIMR claim detail history screen with a newly developed AC crossover disposition indicator, which designates that CWF excluded the claim because the COBA trading partner wished to exclude all adjustment claims.  (See 80.5 of this chapter for a description of this crossover disposition indicator.)  The CWF shall display the new indicator within the eligibility file -based crossover segment of the HIMR detailed claim history screen.  Exception Concerning COBA IDs in the Medigap Claim -based Range   CWF shall never apply the new overarching adjustment claim exclusion logic to incoming HUBC or HUDC claims whose field 34 (Crossover ID) h eader value falls within the range of 0000055000 to 0000059999, which represents the COBA identifier of a COBA Medigap claim -based crossover recipient, and for which there is not a corresponding BOI auxiliary record that likewise contains that insurer identifier.  (See 80.7 of this chapter for more information concerning the COBA Medigap claim -based crossover process.)   O.  Exclusion of Claims Containing Placeholder National Provider Identifier (NPI) Values   Effective October 6, 2008, the CWF maintainer cr eated space within the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a new 1 -byte NPI -Placeholder field (acceptable values=Y or space).   In addition, the CWF maintainer shall create space within page two (2) of the HIMR detail of the claim screen for 1) a new category COBA Bypass; and 2) a 2 -byte field for the indicator BN, which shall designate that CWF auto- excluded the claim because it contained a placeholder provider value (see 80.5 of this chapter for more details regarding the BN bypass indicator).   NOTE:   With the implementation of the October 2008 release, the CWF maintainer shall remove all current logic for placeholder provider values with the implementation of this new solution for identifying claims that contain placeholder provider values.  As MACs adjudicate non VA MRA claims that fall within any of the NPI placeholder requirements, their shared system shall take the following combined actions:   1) Input a Y value in the newly created NPI Placeholder f ield on the HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim transaction if a placeholder value exists on or is created anywhere within the SSM claim record ( NOTE :  Shared systems shall include spaces within the NPI Placeholder field when the claim does not contain a placeholder NPI value); and   2) Transmit the claim to CWF, as per normal requirements.   Upon receipt of claims where the NPI Placeholder field contains the value Y, CWF shall auto -exclude the claim from the national COBA crossover process.  In addition, CWF shall populate the value BN in association with the newly developed COBA Bypass field on page 2 of the HIMR Part B and DME MAC claim detail screens and on page 3 of the HIMR A/B MAC (A) claim detail screen.   P.  Excluding Physician Quality Reporting System  (PQR S) Only Codes Reported on 837 Professional Claims   Effective October 6, 2008, the CWF maintainer shall create space within the header of its HUBC claim transmission for a 1 -byte PQR S indicator (valid values=Q or space).   In addition, CWF shall create a 2 -byte field on page 2 of the HIMR claim detail in association with the new category COBA Bypass for the value BQ, which shall designate that CWF auto -excluded the claim because it contained only PQR S codes (see 80.5 of this chapter for more details regarding the bypass indicator).   Prior to transmitting the claim to CWF for normal processing, MCS  shall input the value Q in the newly defined PQR S field in the header of the HUBC when all service lines on a claim contain PQRI (status M) codes.   Upon receipt of a claim that contains a Q in the newly defined PQR S field (which signifies that the claim contains only PQR S codes on all service detail lines, CWF shall auto-exclude the claim from the national COBA eligibility file -based and Medigap claim -based crossover processes.  Following exclusion of the claim, CWF shall populate the value BQ in association with the newly developed COBA Bypass field on page 2 of the HIMR Part B claim detail screen.