(Medicare Claims Processing Manual)

BY  A BOI record exists, but there are no active BOI entries that correspond to the claim's service dates. Therefore, the claim is bypassed and not crossed over.   80.6 - Special Mass Adjustment and Other Adjustment Crossover Requirements                                                                                                    (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) 1.  Developing a Capability to Exclude Mass Adjustment Claims Tied to the Medicare Physician Fee Schedule Updates and Mass Adjustment Claims -Other  Effective with July 2, 2007, the CWF maintainer create d a new header field for a one (1) -byte mass adjustment indicator within its HUBC, HUDC, HUOP, HUHH, and HUHC claims transaction s.  The valid values for the newly created field shall be M mass adjustment claim- Medicare Physician Fee Schedule (MPFS) and O mass adjustment claim -other.  Further, effective with that date, the BCRC shall send the CWF host sites a modified COIF that contains two new claims exclusion categories:  mass adjustments -MPFS and mass adjustments-other.  Upon receipt of a claim that contains an M indicator (new field) in the header of an HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim, CWF shall read the COIF to  determine whether the COBA trading partner wishes to exclude the claim.  If CWF determines that the trading partner wishes to exclude the mass adjustment- MPFS claim, it shall exclude the claim from the COBA crossover process.   Upon receipt of a claim that  contains an O indicator in the header of an HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim, which designates mass adjustment claim- other, the CWF shall read the COIF to determine whether the COBA trading partner wishes to exclude the claim.  If CWF deter mines that the trading partner wishes to exclude mass adjustment claims -other, it shall exclude the claim from the COBA crossover process.   Creation of New Crossover Disposition Indicators   In relation to its receipt of a claim that has either an M or an  O header value, the CWF shall create two new crossover disposition indicators W (mass adjustment claim -MPFS) and X (mass adjustments claim- other excluded) on the HIMR detailed history screens in association with excluded processed claims for production COBA trading partner.  The CWF shall display each of the new crossover disposition indicators appropriately in association with the processed mass adjustment claim- MPFS on the HIMR detailed history screen.  (See 80.5 of this chapter for further i nformation.)  In addition, the CWF maintainer shall develop and display two (2) new exclusion fields within the COBA Inquiry Screen (COBS) for mass adj.- M (mass adjustments -MPFS) and mass adj. -O (mass adjustments -other).  2.  Developing a Capability to Treat Entry Code 5 and Action Code 3 Claims As  Recycled Original Claims For Crossover Purposes   Effective with July 2007, the CWF maintainer shall create a new header field within its HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims transactions for a 1 -byte -adjustment indicator (valid values=N --non adjustment claim for crossover purposes;  A-- adjustment claim for crossover purposes; or space s).  In instances when CWF returns an error code 5600 to a n A/B MAC or DME MAC,  thereby c ausing it to reset the claims entry code to 5 to action code to 3, the A/B MAC or DME MAC  shall 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, HUIP, HUOP, HUHH, and HUHC claim in the newly defined field before retransmitting the claim to CWF.  The A /B MAC or DME MACs  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.  Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF Beneficiary Other Insurance (BOI) Reply Tra iler 29 for Such Claims   Upon receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) for the recycled claim, the A/B MAC or DME MACs  systems shall ensure that, as part of their 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 shared systems shall ensure that, as part of their 837 flat file creation process, they do not create a corresponding 2330 loop REF*T4*Y segment, which typically signi fies adjustment.   3. Developing a Capability to Treat Claims with Non -Adjustment Entry or Action Codes as Adjustment Claims For Crossover Purposes   In instances where A/B MACs and DME MACs  must send adjustment claims to CWF as entry code 1 or action code 1 (situations where the accrete claim cannot be processed at CWF), they shall set an A indicator in a newly defined field within the header of the HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim.   Upon receipt of a claim that contains entry code 1 or action code 1 with a claim adjustment indicator value of A, the CWF shall take the following actions:    Verify that, as per the COIF, the COBA trading partner wishes to exclude either adjustments, monetary or adjustments, non- monetary, or both ; and    Suppress the claim from crossover if the COBA trading partner wishes to exclude either adjustments, monetary or 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.)   By Passing of Logic to Exclude Adjustment Claim if Original Claim was Not Crossed Over   For purposes of excluding entry code 1 or action code 1 claims that contain an A adjustment indicator value, CWF shall 1) assume that the original claim that was purged from its online history was crossed over, and 2) bypass its logic for crossover disposition indicator R (cross the adjustment claim over only if the original claim was previously crossed over).  Refer to 80.4 of this cha pter for further details regarding this logic.  Actions to Take When A/B MAC or DME MACs Send Invalid Values   If A/B MAC  or DME MAC  sends  claim adjustment indicator values other than N, A, or space within the newly designated header field within their HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims to CWF , CWF shall apply an edit to reject the claim back to the A/B MAC or DME MAC .  Upon receipt of the CWF rejection edit, the shared systems shall correct the invalid value and retransmit the claim to CWF fo r verification and validation.  Creation of a New Crossover Disposition Indicator For This Scenario  In relation to its receipt of a claim that has an A header value, the CWF shall create a new crossover disposition indicator Y (archived adjustment cl aim-excluded)  on the HIMR detailed history screens in association with excluded processed claims for production COBA trading partners.  The CWF shall display the new Y crossover disposition indicator in association with the processed mass adjustment c laim- MPFS on the HIMR detailed history screen.  (See 80.5 of this chapter for further information.)   Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF Beneficiary Other Insurance (BOI) Reply Trailer 29   If A/B MACs  or DME MACs  receive a BOI reply trailer (29) on a claim that had an A indicator set in its header, the A/B MAC or DME MACs  systems shall ensure that, as part of their 837 flat file creation processes, they populate the 2300 loop CLM05- 3 (Claim Frequency Type Code) segmen t with a value that designates adjustment rather than original to match the 2330B loop REF*T4*Y that they create to designate adjustment claim.   If a given shared system does not presently create a loop 2330B REF*T4*Y to designate adjustments, it sha ll not make a change to do so as part of this instruction.    80.7 - Coordination of Benefits Agreement (COBA) Medigap Claim -Based Crossover Process  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  Effective with claims submitted to Medicare on October 1, 2007, and after, participating physicians and suppliers will be expected to include a 5 byte COBA identifier (range 55000---55999) on incoming crossover claims for purposes of triggering claim -based Medigap crossovers.  Additionally, effective with October 1, 2007, claim -based Medigap crossovers will occur exclusively through the BCRC in the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12- N 837 professional clai m format (current version) and National Council for Prescription Drug Programs (NCPDP) claim format.  A.  Changes to A/B MAC or DME MAC Up -Front Screening Processes for COBA Claim -based Medigap Crossovers   Effective with claims that the A/B MACs (B) and DME MACs will cable to CWF on October 1, 2007, their internal processes for screening claims for Medigap claim -based crossovers shall be modified to accommodate the new Medigap claim -based COBA crossover proc ess.  The affected A/B MACs (B) and DME MACs processes for screening claims for Medigap claim -based crossovers shall now feature a syntactic editing of the incoming COBA claim -based Medigap ID to ensure that the identifier begins with a 5 and contains 5 numeric digits.  In addition, for incoming 837 professional and NCPDP claims, A/B MACs (B) and DME MACs shall ensure that the Medigap claim -based COBA ID is entered within the appropriately designated field, loop, or segment of the incoming Medicare claim .  If the claim fails the syntactic verification, the A/B MAC (B) or MAC shall not copy the identifier from the incoming claim and populate it within field 34 (Crossover ID) of the HUBC or HUDC claim transaction that is sent to the CWF for verification a nd validation.  Instead, the A/B MAC (B) or DME MACs shall continue to follow its pre -existing processes for notifying the provider via the ERA or other remittance advice and the beneficiary via the MSN that the information reported did not result in the c laim being crossed over.  The affected A/B MACs (B) or DME MACs screening processes for Medigap claim -based crossovers shall also continue to include verification that the provider participates with Medicare and that the beneficiary has assigned benefits to the provider.   If the provider -populated value for the Medigap claim -based ID passes the A/B MAC (B) or DME MACs syntactic editing process, the affected A/B MAC or DME MACs systems shall copy the Medigap claim -based COBA ID value from the incoming cla im to field 34 of the HUBC or HUDC claims transactions that are sent to CWF for verification and validation.  The A/B MACs (B) and DME MACs shall populate the identifier in field 34 right -justified and prefixed with five zeroes.   B.  CWF Validation of Valu es within Field 34 of the HUBC and HUDC Transactions   Upon receipt of HUBC and HUDC claims that contain a value within field 34 (Crossover ID), the CWF shall read the value that is present within the field for purposes of conducting a validity check.  The CWF shall accept the following values as valid within field 34:  a value within the range of 0000055000 to 0000059999, or spaces.