(Medicare Claims Processing Manual)

1)  Eligibility -based Medigap (30000- 54999); 2) Claim -based Medigap (55000- 59999); 3) Supplemental (00001- 29999); 4) Other Insurer (80000- 80213); 5) Other Insurer (80215 -88999); 6) CHAMPVA (80214); 7) TRICARE (60000- 69999); 8) Medicaid (70000-79999); and 9) Other Health Care Pre -Payment Plan [HCPP] (89000- 89999).  When two or more COBA IDs fall in the same range (see item 24 in the BOI Auxiliary File table above), CWF shall sort numerically within the same range.   3.  CWF Treatment of Non- assigned Medicaid Claims   When CWF receives a non -assigned Medicare claim for a beneficiary whose BOI auxiliary record contains a COBA ID with a current effective date in the Medicaid eligibility -based range (70000 -77999), it shall reject the claim by returning edit 5248 to the A/B MAC (B) shared system only when the Medicaid COBA trading partner is in production mode (Test/Production Indicator=P) with the BCRC .  At the same time, CWF shall only return a Medicaid reply trailer 36 to the A/B MAC (B) that contains the trading partner s COBA ID and beneficiarys effective and termination dates under Medicaid when the Medicaid COBA trading partner is in production mode with the BCRC .  CWF shall determine that a Medicaid trading partner is in production mode by referring to the latest COI F update it has received.   If, upon receipt of CWF edit 5248 and the Medicaid reply trailer (36), the A/B  MAC (B) determines that the non- assigned claims service dates fall during a period when the beneficiary is eligible for Medicaid, it shall convert th e assignment indicator from non-assigned to assigned and retransmit the claim to CWF.  After the claim has been retransmitted, the CWF will only return a BOI reply trailer to the A/B MAC (B) if the claim is to be sent to the BCRC  to be crossed over.   Effective with October 1, 2007, CWF shall cease returning an edit 5248 and Medicaid reply trailer 36 to a DM E MAC.  In lieu of this procedure, CWF shall only return a BOI reply trailer (29) to the DME MAC  for the claim if the COBA Insurance File (COIF) for the State Medicaid Agency indicates that the entity wishes to receive non -assigned claims. NOTE:   Most Medicaid agencies will not accept such claims for crossover purposes.   If CWF determines via the corresponding COIF that the State Medicaid Agency does n ot wish to receive non -assigned claims, it shall exclude the claim for crossover.  In addition, CWF shall mark the excluded claim with its appropriate claims crossover disposition indicator (see 80.5 of this chapter for more details) and store the claim w ith the information within the appropriate Health Insurance Master Record (HIMR) detailed history screen.   DME MACs  shall no longer modify the provider assignment indicator on incoming non-assigned supplier claims for which there is a corresponding COBA ID  in the Medicaid range (70000 -77999).   4.  Additional Information Included on the HUIP, HUOP, HUHH, HUHC, HUBC and HUDC Queries to CWF   Beneficiary Liability Indicators on Part B and DMAC CWF Claims Transactions   Effective with the January 2005 release, the Part B and DM E MAC shared systems shall be required to include an indicator L (beneficiary is liable for the denied service[s]) or N (beneficiary is not liable for the denied service[s]) in an available field on the HUBC and HUDC queries to CWF for  claims on which all line items are denied.  The liability indicators (L or N) will be at the header or claim level rather than at the line level.   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.  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 shal l be included in a field on the HUDC query that is separate from the fields used to indicate whether a beneficiary is liable for all services denied on his/her claim.   The CWF shall read the new indicators passed via the HUBC or HUDC queries for purposes of excluding denied services on claims with or without beneficiary liability and NCPDP claims.   Beneficiary Liability Indicators on Part A CWF Claims Transactions   Effective with October 2007, the CWF maintainer shall create a 1 -byte beneficiary liability indicator field within the header of its HUIP, HUOP, HUHH, and HUHC Part A claims transactions (valid values for the field=L or N).   As A/B MACs (A, HHH)  adjudicate claims and determine that the beneficiary has payment liability for any part of the fully denied services or service lines, they shall set an L indicator within the newly created beneficiary liability field in the header of their HUIP, HUOP, HUHH, and HUHC claims that they transmit to CWF.  In addition, as A/B MACs (A, HHH)  adjudicate claims and determine that the beneficiary has no payment liability for any of the fully denied services or service lines that is, the provider must absorb all costs for the fully denied claims they shall include an N beneficiary indicator within the designated field in the header of their HUIP, HUOP, HUHH, and HUHC claims that they transmit to CWF.   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 w ith beneficiary liability (crossover indicator U) or without beneficiary liability (crossover indicator T).   CWF shall deploy the same logic for excluding Part A fully denied original and adjustment claims with or without beneficiary liability as it now utilizes to exclude fully denied original and adjustment Part B and DME POS claims with and without beneficiary liability, as specified elsewhere within this section.  As of January 4, 2010, CWF shall read action code 8, in addition to action code  1, in association with incoming fully denied original HUIP and HUOP claims.  CWF shall continue to read action code 1 for purposes of excluding all other fully denied original HUHH and HUHA claims.  (See items J and K within this section for more specific s regarding revised logic for exclusion of fully denied HUIP and HUOP adjustment claims.)   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 liability indic ator 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 (A, HHH) sends values other than L or N 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 (A, HHH) or DME MAC  for correction.  Following receipt of the CWF rejec tion, the A/B MAC (A, HHH)  shall change the incorrect value placed within the newly defined beneficiary liability field and retransmit the claim to CWF.   5.  Modification to the CWF Inclusion or Exclusion Logic for the COBA Crossover Process   Beginning wit h the October 2006 release, the CWF or its maintainer shall modify its COBA claims selection logic and processes as indicated below.  The CWF shall continue to include or exclude all other claim types in accordance with the logic and processes that it had in place prior to that release.   D.  New A/B  MAC (B)  Inclusion or Exclusion Logic   The CWF shall read the first two (2) positions of the Business Segment Identifier (BSI), as reported on the HUBC claim, to uniquely include or exclude claims from state -specific A/B MACs (B) or DME MACs , as indicated on the COIF.   E.  Exclusion of Fully Paid Claims   The CWF shall continue to exclude Part B claims paid at 100 percent by checking for the presence of claims entry code 1 and determining that each claims allowe d amount equals the reimbursement amount and confirming that the claim contains no denied services or service lines.   The CWF shall continue to read action code 1 and determine that there are no deductible or co -insurance amounts for the purpose of excluding Part A original claims paid at 100 percent.  In addition, CWF shall determine that the Part A claim contained a reimbursement amount before excluding a claim with action code 1 that contained no deductible and co -insurance amounts and that the claim contained no denied services or service lines.   Claims with Fully Paid Lines, without Deductible or Co -insurance Remaining, and Additional Denied Service Lines   New HUBC Line -Level Indicator Field   Effective January 4, 2010, the CWF maintainer create d a new 1 -byte liability denial indicator (LIAB IND) at the service line level for individually denied claim lines in association with the HUBC claim transaction (valid values=B or spaces).   Part B Shared System Requirements   When the Part B shared system adjudicates claims where most of the claim service detail lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line that are the same as the paid amounts per line and the lines do not carry deductible or co- insurance amounts) but where some detail lines are denied, it shall take the following actions: 1) Input a B value in the newly created 1 -byte LIAB IND field for each denied service line where the beneficiary has payment liability (NOTE:  there may be multiple instances where the B v alue will be applied, contingent upon whether the beneficiary is liable for each of the denied service lines);   2) Input spaces in the newly created 1- byte LIAB IND field for each denied service line where the provider, rather than the beneficiary, is contractually liable for the denied service; and   3) Transmit the HUBC claim to CWF for normal verification and validation processing.   CWF Requirements   The CWF system shall modify its logic for original fully paid claims, without deductible or co -insurance remaining, in association with Part B HUBC claims as follows:   1) Continue to verify the claims entry or action code for confirmation that the claim is an original;  2) Confirm that the claim contains service lines where the amount allowed per line equals the amount paid per line;   3) Check for the presence of a B line LIAB IND in association with any of the denied service lines on the claim;   4) Suppress the claim from the c rossover process if the claim does not contain a B line LIAB IND for any of the denied service lines; and   5) Select the claim for crossover if even one of the denied lines contains a B line LIAB IND.   Upon suppressing the Part B claim from the crossover  process, CWF shall annotate the claim on the Part B claim detail (PTBH) screen with a newly created AF (Fully reimbursable claim containing denied lines with no beneficiary liability) claims crossover disposition indicator.  (See  80.5 of this chapter for more details regarding crossover disposition indicators.)  F.  Claims Paid at Greater than 100 Percent of the Submitted Charge   The CWF shall modify its current logic for excluding Part A original Medicare claims paid at greater than 100 percent of the submitted charges as follows:  In addition to meeting the CWF exclusion criteria for Part A claims paid at greater than 100 percent of the submitted charges, CWF shall exclude these claims only when there is no deductible or co-insurance amounts remaining on the claims.