(Medicare Claims Processing Manual)

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.   NOTE :  The current CWF logic for excluding Part B original Medicare claims paid at greater than 100 percent of the submitted charges/allowed amount (specifically, type F ambulatory surgical center claims, which typically carry deductible a nd co -insurance amounts) shall remain unchanged.  G.  Claims with Monetary or Non-Monetary Changes  The CWF shall check the reimbursement amount as well as the deductible and co -insurance amounts on each claim to determine whether a monetary adjustment change to an original Part A, B, or DM EPOS  claim occurred.   To exclude non-monetary adjustments for Part A, B, and DME POS claims, the CWF shall check the reimbursement amount as well as the deductible and co -insurance amounts on each claim to confirm that there were no monetary changes on the adjustment claim as compared to the original claim.   Effective with April 1, 2008, the CWF shall also include total submitted/billed charges as part of the foregoing elements used to exclude adjustment claims, monetary as well as adjustment claims, non -monetary.  (See sub-section N, Overarching Adjustment Claim Exclusion Logic, for details concerning the processes that CWF shall follow when the COBA trading partners COIF specifies exclusion of all  adjustment claims.)   H.  Excluding Adjustment Claims When the Original Claim Was Also Excluded  When the CWF processes an adjustment claim, it shall take the following action when the COIF indicates that the production COBA trading partner wishes to receive adjustment claims, monetary or adjustment claims, non -monetary:   Return a BOI reply trailer 29 to the A/B MAC or DME MAC  if CWF locates the original claim that was marked with an A crossover disposition indicator or if the original claims crossover disposition indicator was blank/non- existent;    Exclude the adjustment claim if CWF locates the original claim and it was marked with a crossover disposition indicator other than A, meaning that the original claim was excluded from the COBA crossover process.  CWF shall not be required to search archived or purged claims history to determine whether an original claim had been crossed over.   The CWF maintainer shall create a new R crossover disposition indicator, as referenced in a chart within 80.5 of this chapter, to address this exclusion for customer service purposes.  The CWF maintainer shall ensure that adjustment claims that were excl uded because the original claim was not crossed over shall be marked with an R crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.   I.  Excluding Part  A, B, and DME MAC Fully Paid Adjustment Claims Without Deductible and Co -Insurance Remaining   The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) adjustment claims (identified as action code 3 for Part A claims and entry code 5 for Part B and DM EPOS  claims) when the COIF indicates that a COBA trading partner wishes to exclude adjustment claims that are fully paid and without deductible or co-insurance amounts remaining.  Effective with October 1, 2007, CWF develope d logic as foll ows to exclude fully paid Part A adjustment claims without deductible and co -insurance remaining:   1) Verify that the claim contains action code 3;  2) Verify that there are no deductible and co -insurance amounts on the claim;  3) Verify that the reimbursement on the claim is greater than zero; and  4) Confirm that the claim contains no denied services or service lines.   Special Note:   Effective with October 1, 2007, CWF ceased  by-passing the logic to exclude Part A adjustments claims fully (100 per cent) paid in association with home health prospective payment system (HHPPS) types of bills 329 and 339.  The CWF shall exclude such claims if the COIF designates that the trading partner wishes to exclude adjustment claims fully paid without deductible or co -insurance remaining or if these bill types are otherwise excluded on the COIF.   The CWF shall develop logic as follows to exclude Part B or DME POS fully paid adjustment claims without deductible or co -insurance remaining:   1) Verify that the claim contains an entry code 5;  2) Verify that the allowed amount equals the reimbursement amount; and  3) Confirm that the claim contains no denied services or service lines.   The CWF maintainer shall create a new S crossover disposition indicator for adjustment claims that are paid at 100 percent.  The CWF maintainer shall ensure that excluded adjustment claims that are paid at 100 percent shall be marked with an S crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add Adj. Claims -100 percent PD to the COBA Insurance File Summary screen (COBS) on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  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 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 adjustment 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 value 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 a nd validation processing.  CWF Requirements   The CWF system shall modify its logic for adjustment 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 adjustment;  2) Where applicable, also continue to check additionally to determine if the incoming claim contains entry code 5 or  an R recovery audit contractor (RAC) adjustment indicator, as directed in previous CMS instructions;  3) Where applicable, continue to check additionally to determine if the incoming claim contains an entry or action code value of 1, along with Claim Adj ustment Indicator=A, as per previous CMS direction;  4) Confirm that the claim contains service lines where the amount allowed per line equals the amount paid per line;   5) Check for the presence of a B line LIAB IND in association with any of the denied servi ce lines on the claim;  6) Suppress the claim from the crossover process if the claim does not contain a B line LIAB IND for any of the denied service lines; and   7) Select the claim for crossover if even one of the denied lines contains a B LIAB IND.  Upon suppressing the Part B c laim 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.)   J.  Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied with No Additional Liability   The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) fully denied adjustment claims that carry no additional beneficiary liability when the COIF indicates that a COBA trading partner wishes to exclude such claims.   Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment c laim (action code 3) where the entire claim is denied and the beneficiary has no additional liability.  As of January 4, 2010, that logic was changed to also include the reading of action code 8, in addition to action code 3, for HUIP and HUOP claims.  T he revised logic will thus be as follows:  1)  Verify that the claim was sent as action code 3;   2) Verify also if an HUIP or HUOP claim contains action code 8 rather than an action code 3; and   3)  Check for the presence of an N beneficiary liabil ity indicator in the header of the fully denied claim. (See the Beneficiary Liability Indicators on Part A CWF Claims Transactions section above for additional information.)   The CWF shall apply logic to the Part B and DM EPOS  adjustment claims (entry code 5) where the entire claim is denied and the beneficiary has no additional liability as follows:   1) Verify that the claim was sent as entry code 5; and   2) Check for the presence of an N liability indicator on the fully denie d claim.   The CWF maintainer shall create a new T crossover disposition indicator for adjustment claims that are 100 percent denied with no additional beneficiary liability.  The CWF maintainer shall ensure that excluded adjustment claims that were entir ely denied and contained no beneficiary liability shall be marked with a T crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add Denied Adjs-No Liab to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  K.  Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied with No Additional Liability  The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) fully denied adjustment claims that carry additional beneficiary liability when the COIF indicates that a COBA trading partner wishes to exclude such claims.  Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment claim (action code 3) where the entire claim is denied and  the beneficiary has additional liability. As of January 4, 2010, that logic shall be changed to also include the reading of action code 8, in addition to action code 3, for HUIP and H UOP claims.  The revised logic will thus be as follows:  1) Verify that the claim was sent as action code 3;   2) Verify also if an HUIP or HUOP claim contains action code 8 rather than an action code 3; and   3) Check for the presence of an L beneficiary liability indicator in the header of the fully denied claim. (See the Beneficiary Liability Indicators on Part A CWF Claims Transactions section above for additional information.)   The CWF shall apply logic to exclude Part B and DM EPOS  adjustment claims (e ntry code 5) where the entire claim is denied and the beneficiary has additional liability as follows:  1) Verify that the claim was sent as entry code 5; and   2) Check for the presence of an L liability indicator on the fully denied claim.