(Medicare Claims Processing Manual)

Upon receipt of an HUIP, HUOP, HUHH, or HUHC claim that contains an L or N beneficiary liability indicator, CWF shall read the COBA Insurance File (COIF)  to determine whether the COBA trading partner wishes to receive original fully denied claims with beneficiary liability (crossover indicator G) or without beneficiary liability (crossover indicator F) or adjustment fully denied claims with benefic iary liability (crossover indicator U) or without beneficiary liability (crossover indicator T).   If CWF determines that the COBA trading partner wishes to exclude the claim, as per the COIF, it shall suppress the claim from the crossover process.  CWF  shall post the appropriate crossover disposition indicator in association with the adjudicated claim on the HIMR detailed history screen (see 80.5 of this chapter).   In addition, the CWF maintainer shall create and display the new 1- byte beneficiary liab ility indicator field within the HIMR detailed history screens (INPL, OUTL, HHAL, and HOSL), to illustrate the indicator (L or N) that appeared on the incoming HUIP, HUOP, HUHH, or HUHC claim transaction.  CWF Editing for Incorrect Values   If an A/B MAC (Part  A) or A/B MAC (Part  HHH) sends values other than L, N, or space in the newly defined beneficiary liability field in the header of its HUIP, HUOP, HUHH, or HUHC claim, CWF shall reject the claim back to the A/B MAC for correction.  Following rec eipt of the CWF rejection, the A/B MAC (Part  A) and A/B MAC (Part  HHH) shall change the incorrect value placed within the beneficiary liability field and retransmit the claim to CWF.   B.  Developing a Capability to Treat Entry Code 5 and Action Code 3 Claims As Recycled Original Claims For Crossover Purposes  Effective with July 2007, in instances when CWF returns an error code 5600 to an A/B MAC and DME MAC, thereby causing it to reset the claims entry code to 5 and action code to 3, the MAC sha ll set a newly developed N(non-adjustment) claim indicator (treat as an original claim for crossover purposes) in the header of the HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claim in the newly defined field before retransmitting the claim to CWF.  The A/B  MAC and DME MAC shared system shall then resend the claim to CWF.   Upon receipt of a claim that contains entry code 5 or action code 3 with a non- adjustment claim header value of N, the CWF shall treat the claim as if it were an original claim (i.e., as entry code 1 or action code 1) for crossover inclusion or exclusion determinations.  If CWF subsequently determines that the claim meets all other inclusion criteria, it shall mark the claim with an A (claim was selected to be crossed over) crossover disposition indicator.  Following receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) for the recycled claim, the A/B MACs and DME MACs shared systems shall ensure that, as part of their ASC X12 837 flat file creation  processes, they populate the 2300 loop CLM05-3 (Claim Frequency Type Code) segment with a value of 1 (original).  In addition, the A/B MACs and DME MACs shared systems shall ensure that, as part of their ASC X12 837 flat file creation process, they do not create a corresponding 2330 loop REF*T4*Y segment, which typically signifies adjustment.   C.  Developing a Capability to Treat Claims with Non- Adjustment Entry or Action Codes as Adjustment Claims For Crossover Purposes   Effective with July 2007, in instances where A/B MACs and DME MACs must sen d adjustment claims to CWF as entry code 1 or as action code 1 (situations where CWF has rejected the claim with edit 6010), they shall set an A indicator in a newly defined field within the header of the HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim.   If A/B MACs and DME MACs send a value other than A or spaces within the newly designated header field within their HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims, CWF shall apply an edit to reject the claim back to the MAC.  Upon receipt of the CWF rejection edit, the MACs systems shall correct the invalid value and retransmit the claim to CWF for verification and validation.   Upon receipt of a claim that contains entry code 1 or action code 1 with a header value of A, the CWF shall take the follow ing actions:  Verify that, as per the COIF, the COBA trading partner wishes to exclude either adjustments, monetary adjustments, non-monetary, or both ; and    Suppress the claim if the COBA trading partner wishes to exclude either adjustments, monetary adjustments, non-monetary, or both .  NOTE:   The expectation is that such claims do not represent mass adjustments tied to the MPFS or mass adjustments -other.  If A/ B MACs and DME MACs receive a BOI reply trailer (29) on a claim that had an A indicator set in its header, the A/B MACs or DME MACs systems shall ensure that, as part of their ASC X12 837 flat file creation processes, they populate the 2300 loop CLM05-3 (Claim Frequency Type Code) segment with a value that designates adjustment rather than or iginal to match the 2330B loop REF*T4*Y that they create to designate adjustment claim.  If an A/B MACs or DME MACs shared system does not presently create a loop 2330B REF*T4*Y to designate adjustments, it shall not make a change to do so as part of this instruction.  Correcting Invalid Claim Header Values Sent to CWF  If A/B MACs and DME MACs send a value other than A, N, or spaces within the newly designated header field within their HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims, CWF shall ap ply an edit to reject the claim back to the A/B MAC or DME MAC.  Upon receipt of the CWF rejection edit, the A/B MACs or DME MACs systems shall correct the invalid value and retransmit the claim to CWF for verification and validation.  D.  CWF Identifica tion of National Council for Prescription Drug Claims  Currently, the DME MAC shared system is able to identify, through the use of an internal indicator, whether a submitted claim is in the National Council for Prescription Drug Programs (NCPDP) format.  Effective with January 2005, the DME MAC shared system shall pass an indicator P to CWF in an available field on the HUDC query when the claim is in the NCPDP format.  The indicator P should be included in a field on the HUDC that is separate from the fields used to indicate whether a beneficiary is liable for all services that are  completely denied on his/her claim.  The CWF shall read the new indicators passed via the HUBC or HUDC queries for purposes of excluding 100 percent denied claims with or wit hout beneficiary liability and NCPDP claims.  After applying the claims selection options, CWF will return a BOI reply trailer (29) to the A/B MAC or DME MAC only in those instances when the COBA trading partner expects to receive a Medicare processed clai m from the BCRC.   Effective with July 2007, CWF shall reject claims back to DME MACs if their HUDC claim contains a value other than P in the established field used to identify NCPDP claims.  E.  CWF Identification and Auto -Exclusion of ASC X12 837 Professional Claims That Contain Only Physician Quality Reporting Initiative (PQRI) Codes   Effective October 6, 2008, the CWF maintainer shall create space within the header of its HUBC claim transmission for a 1-byte PQRI 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 PQRI codes (see 80.5 of  this chapter for more details regarding the bypass indicator).  Prior to transmitting the claim to CWF for normal processing, the A/B MAC (Part B) shared system shall input the value Q in the newly defined PQRI 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 PQRI field (which signifies that the claim contains only PQRI 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 A/B MAC (Part B) and DME MAC claim detail screens.   Prior to October 6, 2008, all A/B MACs and DME MACs shall update any of their provider customer service materials geared towards crossover claims related inquiries to reflect the newly developed BQ by -pass value, which de signates that CWF auto -excluded the claim because it only contained PQRI codes.   The Next Generation Desktop (NGD) contractor shall also modify its user screens and documentation to reflect the new BQ code.   F.  CWF Identification and Exclusion of Claims Containing Placeholder National Provider Identifiers (NPIs)   Effective October 6, 2008, the CWF maintainer shall create space within the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a new 1 -byte NPI- Placeholder fiel d (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.  (See Pub. 100-04, chapter 27, 80.5 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 A/B M ACs and DME 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 field on the HUIP, HUOP, HUH H, HUHC, HUBC, or HUDC claim transaction if a placeholder value exists on or is created anywhere within the SSM claim record. NOTE :  The A/B MAC and DME MAC shared systems shall include spaces within the NPI Placeholder field when the claim does not cont ain 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 addi tion, 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 screen and on page 3 of the HIMR intermediary claim detail screen.  (See Pub.100- 04, chapter 27, 80.4 for more details.)   Prior to October 6, 2008, all A/B MACs and DME MACs shall update any of their provider customer service materials geared towards crossover claims related inquiries to reflect the newly developed BN by -pass value, which designates tha t CWF auto -excluded the claim because it contained a placeholder provider value.   The Next Generation Desktop (NGD) contractor shall also modify its user screens and documentation to reflect the new BN code.   G.  New CWF Requirements for Other Federal Payers   Effective with October 3, 2011, the CWF maintainer shall expand its logic for Other Insurance, which is COIF element 176, to include TRICARE for Life (COBA ID 60000 -69999) and CHAMPVA (COBA ID 80214), along with State Medicaid Agencies (70000- 79999), as entities eligible for this exclusion.