(Medicare Claims Processing Manual)

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.   Q.  CWF Requirements for Health Care Pre -Payment Plans (HCPPs) that Receive Crossover Claims  Effective January 5, 2009, at CMSs direction, the BCRC  assign ed all HCPP COBA participants a unique 5- byte COBA ID that falls within the range 89000 through 89999. The CWF system shall accept the reporting of this COBA ID range.  (Refer to chapter 28, 70.6 for MAC requirements in association with HCPP and HMO cost plan crossovers.)  R.  Inclusion or Exclusion of Part A Claims By Provider Identif ication Number (ID) as well as Provider State  Since July 2004, the CWF has read the incoming BCRC -created COIF to determine each national COBA trading partners specific claims selection as tied to each COBA ID.  To accommodate the inclusion or exclusion of Part A specific provider identifiers (IDs), CWF currently reads the numeric value reported on the COIF by COBA ID and then interrogates the Provider ID, CMS Certification Number (CCN) reported on the incoming HUIP, HUOP, HUHH, or HUHC claims transacti on.  For instances where a match is found, CWF either includes or excludes the claim from the national crossover process, in accordance with the I or E indicator that precedes the provider ID value reported beginning with field 225 of the COIF.  Also, since July 2004, CWF has read the 2- digit state code as referenced on the COIF as a basis for including or excluding Part A claims by provider state.  In performing this function, CWF locates the incoming Provider ID on the HUIP, HUOP, HUHH, or HUHC clai ms transaction and determines if the first 2 bytes match the 2 -byte state code on the BCRC -created COIF.   If a match is found, CWF either includes or excludes the claim based upon the I or E value reported in field 224 of the COIF.  Effective April 4,  2011, upon its receipt of either a 6-byte CMS Certification Number (CCN) or a 10 -digit NPI, as found starting in position 225 of the COIF, CWF shall check both the Provider ID and NPI fields of the incoming HUIP, HUOP, HUHH, or HUHC for potential matc hes.  If CWF finds a provider ID or NPI match, it shall either include or exclude the claim based upon the indicator (I or E) reported in field 224 of the COIF.   The CWF shall continue to either 1) include  the claim if the I indicator precedes the provider ID or NPI reported on the COIF or  2) exclude the claim and annotate Part A claims history with crossover indicator K when the reported provider ID or NPI on the COIF is identified for exclusion from the crossover process. (See 80.5 of this chapter f or more information concerning the K crossover disposition indicator.)  S.  Excluding Fully Denied Claims Adjudicated With An Other Adjustment (OA) Claim Adjustment Segment Group Code   Effective October 4, 2010, the CWF maintainer create d space within the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a 1 -byte Claim Adjustment Segment (CAS) Group Code Indicator field (valid values=G or space).  In addition, CWF developed a new 2 -byte BG COBA By -pass indicato r, which designates that CWF auto -excluded the claim because it was adjudicated with an OA CAS group code for all denied lines or services.  Prior to transmitting their adjudicated claims to CWF for normal processing, all shared systems shall input the value G in the newly defined 1-byte CAS Group Code Indicator field in the header of their HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claims when all services or claim detail service lines on the affected claims are denied with Group Code OA.  Upon receipt of a claim that contains a G in the newly defined CAS Group Code Indicator field, CWF shall auto- exclude the claim from the national COBA eligibility file-based and Medigap claim -based crossover processes.  ( NOTE:   CWF shall not be required to read the COIF to determine COBA trading partner preferences for claims containing either an L or N beneficiary liability indicator when the incoming claim contains a G in the newly defined CAS Group Code Indicator field.)  Following auto-exclusion of the cl aim, CWF shall take the following actions:  1)  Annotate the claim with a BG COBA bypass indicator; and   2)  Display the BG indicator as part of the COBA Bypass segment on page 3 of the appropriate HIMR claim detail screen.   Effective with October 3, 2011, CWF create d a consistency edit that will activate when the shared systems send HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims to CWF that contain a value in the CAS Group Code Indicator field other than G or spaces.  Upon receipt of this consistency edit, the shared system shall take the following actions:  1) Modify the value reported in the CAS Group Code Indicator either to a G, if appropriate, or spaces; and   2) Retransmit the claim to CWF.   T.   New Requirements for Other Federal Payers   Effective wi th October 3, 2011, the CWF maintainer expand ed 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 eligibl e for this exclusion.   Through these changes, if either TRICARE for Life or CHAMPVA wishes to invoke the Other Insurance exclusion, and if element 176 is marked on the COIF for these entities, CWF shall suppress claims from the national COBA crossover process if it determines that the beneficiary has active additional supplemental coverage.   As part of this revised Other Insurance logic for TRICARE and CHAMPVA, CWF shall interpret additional supplemental coverage as including entities whos e COBA identifiers fall in any of the following ranges:   00001- 29999 (Supplemental);  30000- 54999 (Medigap eligibility- based);  80000- 80213 (Other Insurer); and  80215- 88999 (Other Insurer).   The Other Insurance logic for State Medicaid Agencies includes al l of the following COBA ID ranges:   00001- 29999 (Supplemental);  30000- 54999 (Medigap eligibility- based);  60000- 69999 (TRICARE);  80000- 80213 (Other Insurance)  80214 (CHAMPVA)  80215- 88999 (Other Insurer).   NOTE:   As of October 3, 2011, CWF shall now omit COBA ID range 89000- 89999 as part of its Other Insurance logic for State Medicaid Agencies.   CWF shall mark claims that it excludes due to Other Insurance with crossover disposition indicator M when storing t hem within the CWF claims history screens.  (See 80.5 of this chapter for additional information concerning this indicator.)   U.  CWF and Shared Systems Handling of Claims Where Principal Diagnosis Is E Code or Equivalent Code in Successive ICD Diagnosi s Versions   Effective April 1, 2013, CWF create d a new 1 -byte First Reported DX Code Indicator field within the header of incoming HUBC and HUDC claims transactions.  CWF shall only accept Y or spaces as valid values for the newly created First Reported DX Code Indicator within the header of incoming HUBC and HUDC claims and shall develop consistency edits to address invalid values submitted in the newly created field.  For applicable situations where claims having a principle (first -listed) E ICD -9 code or, when ICD -10 diagnosis coding is implemented,  equivalent V00--Y99 ICD -10 diagnosis code are either not rejected due to front -end editing or are returned as unproces sable, the Part B and DME MAC shared systems shall:    Input a Y indicator in the First Reported DX Code field (header) of the HUBC and HUDC  claims; and    Transmit the affected claims to CWF for normal processing.   The shared systems shall have the abilit y to react to CWF consistency edits received when invalid values are entered in the newly created DX Code Indicator field.  Upon receipt of claims that contain a Y in First Reported DX Code Indicator field, CWF shall by -pass the claims from crossing over .  CWF shall create a new BX COBA by-pass indicator that it will apply to claims where a Y is present within the DX Code Indicator field (See 80.5 of this chapter for more information regarding the new indicator).  Additionally, CWF shall display the new by- pass indicator on the appropriate page(s) of the HIMR claims detail screens.   80.5 - Claims Crossover Disposition and Coordination of Benefits Agreement Bypass Indicators  (Rev. 4474, Issued; 12- 06-19, Effective: 01 -04-20, Implementation: 01- 06-20)  1.  Claims Crossover Disposition Indicators   Effective with the October 2004 systems release, when a COBA trading partner is in production mode (Test/Production Indicator sent via the COIF submission=P), CWF shall annotate each processed claim on detailed  history in the HIMR with a claims crossover disposition indicator after it has applied the COBA trading partners claims selection criteria.  (See the table below for a listing of the indicators.)  In addition, when a COBA trading partner is in production mode, CWF shall annotate each processed claim with a 10-position COBA ID (5 -digit COBA ID preceded by 5 zeroes) to identify the entity to which the claim was crossed or not crossed, in accordance with the terms of the COBA.  Effective with October 2006, t he CWF maintainer updated its data elements/documentation to capture the revised descriptor for crossover disposition indicators E, as reflected below.  In addition, the CWF maintainer shall update its data elements/documentation to capture the newly add ed R, S, T, U, and V crossover disposition indicators, as reflected in the Claims Crossover Disposition Indicators table below.   Effective with July 2007, the CWF maintainer updated its data elements/ documentation to capture the newly added W, X, and Y crossover disposition indicators, as well as all other changes, reflected in the table directly below.