(Medicare Claims Processing Manual)

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.   If the A/B MAC (B) or DME MAC has sent an inappropriate value in field 34 of the HUBC and HUDC claims transaction, CWF shal l return an alert code 7704 on the 01 disposition response via the claim -based alert trailer 21.   For customer service purposes, the CWF maintainer shall create a new crossover disposition indicator Z to accommodate the scenario of the A/B MAC (B) or DME MAC sending an incorrect value within field 34 of the HUBC and HUDC transaction.  (See 80.5 of this chapter for more information regarding this crossover disposition indicator.)  At the point that CWF returns an alert code 7704 to the affected A/B MAC  (B) or DME MAC, it shall take the following actions with respect to the claim:  1.  Mark the claim with crossover disposition indicator Z (invalid Medigap claim -based crossover ID included on the claim); and  2.   Display the indicator, together with the invalid COBA ID value from field 34, in association with the claim on the appropriate HIMR detailed history screen in the claim -based crossover segment.   See Pub.100- 04 chapter 28, 70.6.4 for an explanation of A/B MAC or DME MAC processes following receipt of a CWF alert code 7704 via a 21 trailer.   C.  CWF Processing for COBA Claim-based Medigap Crossovers  Following receipt of an HUBC and HUDC claims transaction that contains a valid value within field 34 (a value within the range of 0000055000 to 0000059999 or spaces), CWF shall check for the presence of a BOI auxiliary record for the purpose of triggering eligibility file -based crossovers.  CWF shall then read the COIF to determine the claims selection criteria for any eligibility file -based tradi ng partners (all other COBA IDs) as well as for the Medigap claim -based insurer (range 0000055000 to 0000059999).  If the HUBC or HUDC claim contains a valid COBA Medigap claim-based ID within field 34 but the valid ID cannot be found on the COIF, the CWF shall post the valid COBA Medigap claim -based ID without an accompanying crossover disposition indicator in association with the claim within the claim-based crossover segment of the appropriate HIMR claim detailed history screen.   If the claim meets the  COBA trading partners selection criteria, as per the COIF, and none of the other scenarios presented below applies, CWF shall return a Beneficiary Other Insurance (BOI) reply trailer (29) to the A/B MAC (Part B) or DME MAC for purposes of having the A/B MAC (B) or DME MAC trigger a crossover to the BCRC.   Duplicate Check   The CWF shall perform a duplicate check to determine if the beneficiary is identified for crossover to a Medigap eligibility file-based insurer (COBA ID 30000-54999) and to a Medigap claim-based insurer (COBA ID 0000055000-0000059999).  If CWF determines that the beneficiary is identified for crossover to both a production Medigap eligibility file-based insurer (COBA ID range=30000 to 54999) and a Medigap claim- based Medigap insurer (COBA ID range=0000055000 to 0000059999), it shall suppress the BOI reply trailer (29) for the claim-based Medigap insurer (COBA ID range= 0000055000 to 0000059999).  Crossover Disposition Indicator AA  Effective with October 1, 2007, the CWF maintainer created a new crossover disposition indicator AA to accommodate the CWF duplicate check, where it has determined that the beneficiarys claim is eligible for crossover to both a production Medigap eligibility file-based insurer and  a Medigap claim -based crossover insurer.  After CWF has determined that beneficiary has already been identified for Medigap eligibility file- based crossover, it shall take the following actions with respect to the claim:   1.  Mark the associated claim with indicator AA (beneficiary identified on Medigap insurer eligibility file; duplicate Medigap claim-based crossover voided); and   2.  Display this indicator, together with the affected claim- based Medigap COBA ID, in association with the claim on the appropriate HIMR detailed history screen in the claim -based crossover segment.  D.  BOI Reply Trailer (29) Process   If CWF determines that the claim meets the trading partners claims selection criteria, it shall select the claim and return a BOI reply trailer 29 for the claim to the affected A/B MAC (B) or DME MAC.  The CWF shall display the appropriate crossover disposition indicator for the claim- based crossover claim within the claim- based crossover segment of the HIMR claim detailed history screens.  As with the COBA eligibility file -based crossover process (see 80.4 of this chapter for more details regarding this process), CWF shall display the COBA ID and accompanying crossover disposition indicator on claim detailed  history screens, with the exception of circumstances where the valid ID cannot be located on the COIF, as discussed above, or the Medigap claim -based insurer is in test mode with the BCRC.  In these situations, only the COBA Medigap claim -based ID shall  be displayed.   Modification of the CWF Sort Routine For Multiple COBA IDs and Accompanying A/B MAC or DME MAC Actions Following Receipt of the BOI Reply Trailer (29)   In light of the new COBA Medigap claim -based crossover process, the CWF sort routine for COBA IDs to be returned via the BOI reply 29 trailer shall be modified as follows:  Medigap eligibility file -based (30000- 54999), Medigap claim -based (55000- 59999), supplemental (00001- 29999), TRICARE for Life (60000- 69999), Other insurer (80000 -89999), a nd Medicaid (70000- 79999).  (NOTE:  This information is also being updated in 80.4 of this chapter)   Upon receipt of the BOI reply trailer (29), the affected A/B MAC (B) or DME MAC shall continue to utilize information from this source to populate the beneficiarys MSN and provider ERA or other remittance advice in production in accordance with the existing guidance that appears in 80.4 of this chapter. 80.8 -  Inclusion and Exclusion of Specified Categories of Adjustment Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  1. CWF Inclusion of Adjustment Claims   Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion  of adjustment claims option, along with 1 -byte file displacement, within its version of the COIF; and 2) accept and process this new field when the BCRC transmits it as part of its regular COIF updates.   Upon receipt of a COIF that features a COBA identification number (ID) with specifications to include adjustment claims only, the CWF shall select only those claims for COBA crossover that meet the following specifications:   1) The claims action code=3, entry code=5, or claim adjustment indicator=A all of which designate an adjustment claim; and   2) The claim meets no other exclusion criteria, as specified on the COIF, or  does not meet the NPI placeholder value by-pass exclusion logic.  With the implementation of this change, the CWF shall continue to select adjustment claims only if it previously selected the original claim for crossover (logic for adjustment indicator R; see 80.4 of this chapter for additional details regarding this logic).  If the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the new designated RAC adjustment indicator field, CWF shall select the claim in accordance with the COBA trading partners claims selection criteria specified on the COIF.   2.  CWF Inclusion of Two Categories of Mass Adjustment Claims for Crossover Purposes   Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion of mass adjustment claims MPFS updates and mass a djustment claims other options, along with accompanying 1- byte file displacement indicators, within its version of the COIF;  and 2) accept and process these new fields when the BCRC transmits them as part of its regular COIF updates.  Upon receipt of a HUI P, HUOP, HUHH, HUHC, HUBC, or HUDC claim transaction, CWF shall take the following actions:  1) Verify that the claim transaction contains an M or O mass adjustment claim header indicator; 2) verify that the claims action code=3, or entry code=5, or adjustment header indicator=A; 3) check the COIF to determine if the COBA trading partner wishes to include mass adjustment claims MPFS or mass adjustment claims --other; 4) include the claim for crossover, unless the original claim was not  crossed over (l ogic for crossover disposition indicator R) or the claim meets any claims exclusion criteria as specified on the COIF.   If the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the mass adjustment indicator field, CWF shall select the claim per the COBA trading partners claims selection criteria, as specified on the COIF.   3.  CWF Inclusion and Exclusion of Recovery Audit A/B MAC or DME MAC (RAC)-Initiated Adjustment Claims   At CMSs direction, the BCRC has modified the COIF to allow for the unique inclusion  and exclusion of RAC- initiated adjustment claims.  The CWF system shall 1) create the newly defined inclusion and exclusion of RAC -initiated adjustment options, along with  accompanying 1-byte file displacement, on its version of the COIF;  and 2) accept and process these new fields when the BCRC transmits them as part of its regular COIF updates.  Effective January 5, 2009, the CWF maintainer created a 1 -byte RAC adjustment value in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions (valid values= R or spaces.)   The CWF maintainer shall, in addition, include the 1- byte RAC adjustment indicator in the header of the claim that is posted to history on HIMR, thereby ensuring that CWF displays the indicator when a user accesses the INPH, OUTH, PTBH, DMEH, and related HIMR screens.    Shared System Actions   All shared systems shall develop a method for uniquely identifying all varieties of RAC -requested ad justments, which occur as the result of post -payment review activities.   Prior to sending its processed 11X and 12X type of bill RAC adjustment transactions to CWF for normal verification and validation, the Part A shared system shall input an R indicato r in the newly defined header field of its HUIP claims transactions if the RAC -initiated adjustment claim meets either of the following conditions:   1)  The claim recovery action resulted in Medicare changing its payment decision from paid to denied (i.e., Medicare paid $0.00 as the result of the adjustment performed); or   2)  The claim recovery action resulted in a Medicare adjusted payment amount that is equal to or greater than  the amount of the inpatient hospital deductible.  Prior to sending RAC -initiated adjustment claims with all other type of bill designations   (bill types other than 11X and 12X) to CWF for normal processing, the Part A shared system shall input an R indicator in the newly defined header field of the HUOP , HUHH, and HUHC claim transaction.