(Medicare Claims Processing Manual)

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.   Prior to sending their processed RAC adjustment transactions to CWF for normal verification and validation, the Part B and DME MAC shared systems shall input an R indicator in the newly defined header field of their H UBC and HUDC claim transactions.  (See chapter 28, 70.6 for more details.)   CWF Actions   Upon receipt of a claim that contains an R in its header in the newly defined field, CWF shall take the additional following actions:   1) Verify that the claims ac tion code=3, entry code=5, or header claim adjustment indicator=A;   2) Check the COIF to determine if the COBA trading partner wishes to include  RAC -initiated claims;  3) Include  the claim for crossover, unless  the original claim was not crossed over (logic for crossover disposition indicator R) or the claim meets any other claims exclusions specified on the COIF; or   4) Exclude  the claim if the COIF specifies exclusion of RAC -initiated adjustment claims .  In addition, if the incoming H UIP, 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, as specified on the COIF.    80.9 - Health Insurance Portability and Accountability Act (HIPAA) 5010 and National Council for Prescription Drug Programs (NCPDP) D.0 Crossover Requirements  (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) Effective January 5, 2009, the BCRC  created a new 1 -byte 5010 Test/Production Indicator and a new 1 -byte NCPDP D.0 Test/Production Indicator on the COBA Insurance File [COIF] (valid values= Nnot applicable or not ready as yet; Ttest; Pproduction).  The CWF maintainer shall 1) create these new fields, along with 1 -byte file displacement, 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.  If the BCRC transmits a value other than T, P, or N within the newly designated fields, CWF shall ignore the value.  In addition, the CWF maintainer shall add a new 5010 Test/Production Indicator and an NCPDP D.0 Test/Production Indicator to the BOI reply trailer (29) f ormat.   The CWF shall not  post crossover disposition indicators in association with claims whose 5010 and NCPDP D.0 indicators are N or T. (Refer to 80.5 of this chapter for more information regarding claims crossover disposition indicators.)   80.10 - Inclusion and Exclusion of Specified Part B Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes  (Rev.  4474, Issued; 12- 06-19, Effective: 01-04-20, Implementation: 01-06-20) Effective April 6, 2020, CWF shall begin to support the inclusion  and exclusion of Part B psychotherapy claims via the COBA crossover process.  Inclusion of Part B Psychotherapy Claims  When CWF determines through reading the modified COBA Insurance File (CO IF) that a COBA trading partner wants to receive Part B psychotherapy claims only, it shall select the claim for crossover purposes under the following circumstances:  The claims Part B psychotherapy provider specialty code (i.e., code 26, 62, 68, 80, or 89), as received via the Health Utilization Part B claim (HUBC) transaction, matches the COIF specifications for inclusion of Part B psychotherapy claims; and  The claim does not otherwise meet other exclusion logic specified on the COIF; and  As applicable, the corresponding original claim was not previously excluded from crossing over. (Note:   This relates to the CWF crossover disposition code R logic and applies to adjustment claims.  See Section 80.5 for more information regarding crossover disposition code R.) Exclusion of Part B Psychotherapy Claims In determining whether a base COBA trading partner (i.e., an insurer or other health benefit organization that carves out the processing and payment of mental health claims to another organization) wishes to exclude Part B psychotherapy claims through the COBA process, CWF shall:   Verify if the claim's Part B psychotherapy provider specialty code matches the COBA trading partner's exclusion criteria per the COIF; and  Exclude the claim if a match is found. Important:  The CWF maintainer shall permit the inclusion or exclusion of some or all Part B psychotherapy provider specialty codes in accordance with the information specified on the COIF. Crossover Disposition Indicators  CWF shall create a new COBA crossover disposition indicator AG (see Section 80.5 for further details regarding this crossover disposition indicator) that it will apply when the HUBC claim does not meet the provider specialty code inclusion criteria.   In addition, CWF shall create a new COBA crossover disposition indicator AH (see Section 80.5) that it will apply when the base COBA trading partner specifies it wishes to exclude Part B psychotherapy claims from crossing over. As applicable, CWF shall display the new AG and AH crossover disposition indicators on page 2 of the PTBL claims detail screen on HIMR.       Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11427CP  05/20/2022  Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) 01/03/2023 12734 R11414CP  05/12/2022  Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) - Rescinded and replaced by Transmittal 11427 06/13/2022 12734 R11396CP  05/04/2022  Update to  Chapters 3, 4, 27 and 37 of Publication (Pub.) 100- 04 Medicare Claims Processing Manual to Remove Reference to the Term "OSCAR"  10/03/2022 12715  12/06/2019  Updates to the Coordination of Benefits Agreement Insurance File (COIF) For Use in the National Coordination of Benefits Agreement (COBA) Crossover Process  04/06/2020 11380 R4454CP  11/08/2019  Updates to the Coordination of Benefits Agreement Insurance File (COIF) For Use in the National Coordination of Benefits Agreement (COBA) Crossover Process - Rescinded and replaced by Transmittal 4474 04/06/2020 11380 R4220CP  01/25/2019  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  07/01/2019 11092 R4088CP  07/13/2018  Update to the Internet Only Manual (IOM) Publication 100-04 - Medicare Claims Processing Manual, Chapter 27 - Contractor Instructions for Common Working File (CWF)