(Medicare Claims Processing Manual)

2010BB-N3 & 2010BB- N4:  a. N301 & N302populate spaces; and b. For N401, N402, N403, N404, N407, populate spaces.  17. FISS shall not creat e the 2010AC loop within the 837 new version COB flat file.  18. If FISS notes the presence of other payers within 2320 SBR and 2330B loops that had made no financial determination on a claim prior to Medicare, as in the case of Medicare secondary payer (MSP) situations, the shared system shall not move those loops to the 837 new version COB institutional flat file.  ( NOTE:   The shared system shall continue to populate information as received from the CWF BOI reply trailer (29) within the 2320 SBR and 2330 loops of the associated ASC X12 837 COB flat file fields.)  19. The 2330B loop denotes other payers for the claim following Medicare.  All should note that there will always be one (1) 2330B that denotes Medicare as a payer, with FISS completing all required information for NM101, NM102, NM103, NM108, NM109, as well as the N3 and N4 segments.   20. For additional 2330B loop iterations relating to COB, if the A/B MAC receives multiple COBA IDs via the BOI reply trailer (29), payer information for additional COBA IDs will be unknown.  As with the 2010BB loop, the NM1 segmen t should be formatted as follows, with BCRC completing missing information:  2nd and additional iterations of 2330BNM1:   a. NM101populate PR:  b. NM102populate 2; c. NM103populate spaces; d. NM108populate PI; and  e. NM109populate the COBA ID (5 digit COBA ID as obtained from the BOI reply trailer 29).   2nd and additional iterations of 2330B-N3 & 2330B- N4:  a. N301 & N302populate spaces; and b. For N401, N402, N403, N404, N407, populate spaces.  21. FISS shall always send at least one (1) complete iteration of 2320, 2330A, and 330B on all ASC X12 837 COB flat files.  22a. FISS shall populate the required 2310-A (Attending Provider Name), 2310B (Operating Physician Name), and 2310C (Other Operating Physician Name) NM1 segments, with information derived from the incoming electronic claim.  FISS shall always populate the NM108 segment always indicating XX and shall derive the NPI from the incoming claim.   22b. If the incoming claim is paper or DDE entered, FISS shall derive the attending, operating, and other operating physician name from the Form CMS-1450 claim or DDE entry, or as necessary from the A/B MAC (A or HH)s internal provider files.  FISS shall always populate the NM108 segment with XX and shall derive the NPI from the Form CMS-1450 claim or DDE entry screen.  23. When the incoming claim is paper, Form CMS-1450 or DDE entered, FISS shall continue with all other mapping practices not otherwise addressed above when creating the outbound skinny 837 COB flat file.  [For example, FISS shall continue to derive the discharge hour, admission date/hour, admission source code, medical record number, principal diagnosis, admitting diagnosis code, principal procedure information, occurrence codes, occurrence span codes, value codes, and condition codes from the associated FL fields of the Form CMS -1450 or from the DDE keyed information.]  24. FISS shall migrate the Line Item Control Number data from the Store and Forward Repository (SFR) to the area of the ASC X12 837 COB flat file that  corresponds to loop 2400, REF02, where REF01=6R, as per the Implementation Guide.  25. Upon implementation of the 5010 Errata changes, FISS shall take the following action with respect to the creation of the field corresponding to 2300 CL101 on the 837 COB f lat file as a gap -fill or systems -fill value when necessary:   Map the value 9 (Information Not Available) to the field corresponding to 2300 CL101 on the ASC X12 837 COB flat file if the incoming claim is received in a claim format other than the new, no w current version, and the CWF BOI reply trailer 29 indicator for the new, now current version returned to the A/B MAC (A or HH) for the claim= T or P.  B. ASC X12  837 Professional COB Claim Mapping Rules  Effective with the testing and implementatio n of the Health Insurance Portability and Accountability Act (HIPAA) ASC X12 837 professional new and now current version, the Multi- Carrier System (MCS, the A/ B MAC (B) shared system) and the ViPS Medicare System (VMS, the DME MAC shared system) shall ob serve the following common business rules for mapping of the new and now current version COB (professional) flat file:    1 The following segments shall not  be passed to the BCRC :  a. ISA (Interchange Control Header Segment); b. IEA (Interchange Control Trailer Segment);  c. GS (Functional Group Header Segment); and d. GE (Functional Group Trailer Segment).   2. The shared system shall map the claim version (new and now current version) in the field of the ASC X12 837 new version COB flat file that corresponds to the ST03 segment.    3. The BHT02 (Beginning of the Hierarchical TransactionTransaction Set Purpose Code) shall be passed either with value 00 or 18 under the following circumstances:   a. Normal claims submission to the BCRC use 00 ; and b. COB A claims repair process use 18.  4. The BHT03 (Beginning of the Hierarchical TransactionReference Identification or Originator Application Transaction ID) shall contain identifiers populated as follows:  a. 23 bytes for non- COBA recovery claims as follo ws:   Bytes 1 -9A/B MAC (B) or DME MAC ID (9 bytes; A/B MAC or DME MAC ID, or 5 bytes left justified, followed by 4 spaces);  Bytes 10- 14Julian Date (5 bytes, expressed as YYDDD);  Bytes 15- 19Sequence Number (5 bytes, starting with 00001; should increment for each ST -SE envelope);  Bytes 20- 21Claim Version Indicator (2 bytes; values=50 for 5010 claims); and Byte 22Test/Production Indicator (1 byte; valid values=T test; P production); and  Byte 23Original versus Adjustment Claim Indicator (1 b yte)-Valid Values are:  Efor re processe d claims that for merly included an electronic  prescribing (e-RX) negative adjust ment amount;  Ofor original claims; P for Affordable Care Act or other congressional imperative mass adjustments; Mfor non- Affordable Care Act mass adjustments tied to Medicare Physician Fee Schedule (MPFS);  Sfor mass adjustment claims all others; Rfor RAC adjustment claims; and  Afor routine adjustment claims, not previously classified.  Additionally, as of April 7, 2014:  C  for CMS -directed mass adjustment action (use specified by CMS);  Vfor void/cancel only claim   b. 23 bytes for COBA recovery claims as follows:   Bytes 1 -9A/B MAC (B) or DME MAC ID (9 bytes; A/B MAC (B) or DME MAC ID, left justified, or 5 bytes followed by 4 spaces);  Bytes 10- 14Julian Date (5 bytes, expressed as YYDDD);  Bytes 15- 19Sequence Number (5 bytes, starting with 00001; should increment for each ST -SE envelope);  Bytes 20- 21Claim Version Indicator (2 bytes; values=50 for 5010 c laims); and  Byte 22COBA recovery indicator (1 byte; indicator =R)  Byte 23Original versus Adjustment Claim Indicator (1 byte)   (NOTE:  See II.B.4.a directly above for valid values.)   5. The 1000- A PER (Submitter EDI Contact Information) shall be populate d as follows:   a. PER01 populate 1C;  b. PER02 populate BCRC EDI Department;  c. PER03 populate TE; and  d. PER04 populate 6464586740.   6. The 1000- B loop NM1 (Receiver Name) denotes the crossover trading partner.  If the A/B MAC (B) or DME MAC receives multiple COBA IDs via the BOI reply  trailer (29), the shared system shall submit a separate ASC X12 837 transaction for each COBA ID received .  Since crossover trading partner information will be unknown to the shared systems, the shared system shall format the following fields as indicated:   a. NM101populate 40; b. NM102populate 2; c. NM103populate spaces; d. NM108populate 46; and e. NM109include COBA ID (5 -digit COBA ID obtained from the BOI reply trailer 29).   7a. For all 2000A, 2310B, and 2420A PRV (Billing Provider Specialty Information) segments, the A/B MAC ( B) and DME MAC shared systems shall map the taxonomy code values reported in PRV01 through PRV03 on the incoming electronic claim to the corresponding fields within the ASC X12 837 COB flat file.  If the values reported for these loops on the incoming claim are incomplete or syntactically incorrect, the shared system shall not create the loop and associated segments.   7b. The A/B MAC (B) shared system shall continue the practice of only mapping 2420A- level PRV segments if the incoming electronic claim is multi- line, with differing rendering physicians associated to each line.  The A/B MAC ( B) shared system shall not map a 2420A-level reported PRV segment if the incoming electronic claim contains a single detail line.   8. The A/B MAC (B) and DME MAC shared systems shall derive information for 2010AA PER 03, PER04, PER05, and PER06 if such information is present and syntactically complete within the A/B MAC (B) or DME MACs internal provider files.  If such information is unavailable or incomplete, the affected shared systems shall not create the 2010AA PER loop on the ASC X12 837 new version professional COB flat file.  9. The A/B MAC (B) and DME MAC shared systems shall derive all provider specific information necessary to populate the NM1 and N3 and N4 segments of such loops as 2010AA, 2010AB, and 2310B from each A/B MAC (B) or DME MACs  internal provider files.  In addition, where a providers tax ID is required within a secondary REF segment, the shared systems shall also derive this information from each A/B MAC (B) or DME MACs internal provider files.  10a. For 2320 SBR01, in situations where there is only one (1) payer that is primary to Medicare, VMS shall apply P to any payer that is primary before Medicare; S for Medicare as the secondary payer; and U for all supplemental payers after Medicare.     S PECIAL NOTE:  I f, for example, a claim contains at least two (2) primary payers before Medicare, the DME MAC shared system shall reflect the primary payer as 2320 SBR01as P; the secondary payer as 2320 SBR01 = S; and, the tertiary payer, Medicare, as 2320 SBR01 = T.  MCS shall reflect all additional supplemental payers as 2320 SBR01 = U.  10b. For 2000B SBR01 (element 1138), the shared system shall apply P when Medicare is the primary payer and shall apply U for all other supplemental payers after Medicare.   11. For additional 2000B requirements, the shared system shall take the following actions:   a. SBR03 map spaces; and  b. SBR09 If the COBA ID returned via the BOI reply trailer (29)=70000-79999, map MC; for all other COBA IDs, map  CI.  12. The 2010BA loop denotes beneficiary subscriber information.  There are two (2) crossover scenarios to address:  regular, eligibility file -based crossover, and Medigap claim -based crossover.