(Medicare Claims Processing Manual)

IV. Other ASC X12 837 New Version COB Requirements    A. Complementary Credits   Upon receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) that contains a P ASC X12 837 indicator, the shared systems shall ensure that their affiliate A/B MACs and DME MACs are able to:  1) book complementary credits for the affected claim; and 2) transmit the production claim to the BCRC after it has finalized on the A/B MAC or DME MACs payment floor.  Following receipt of a BOI reply trailer (29) that contains a T ASC X12 837  indicator, as applicable, the shared systems shall ensure that their affiliate MACs:  1) do not anticipate receipt of complementary credits for that version of the claim; and 2) transmit the test claim to the BCRC after it has finalized on the contractors payment floor.   All shared systems shall, in addition, not expect complementary credits in association with their affiliated A/B MAC or DME MACs receipt of a CWF BOI reply trailer (29) that con tains an N new version indicator.  B. BCRC Business- Level Editing of Incoming New Version COB Flat Files   With the implementation of the new version claim standards, the BCRC will apply business level edits to ensure that incoming claims possess the structure necessary for successful translation into the HIPAA ASC X12 837 new version claim formats.  See 70.6.1.1 of this chapter for charts that define the 111 level errors that the BCRC will return to the A/B MACs or DME MACs when their incoming ASC X12 837 COB flat files cannot be utilized to build compliant outbound ASC X12 837 claim transactions.  70.6.6 - National Council for Prescription Drug Programs (NCPDP) Version D.0 Coordination of Benefits (COB) Requirements  (Rev. 4281, Issued: 04- 19-19, Effec tive: 05 -20-19, Implementation: 05-20-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   I - BASIC REQUIREMENTS   Prior to the mandatory cut- over to the NCPDP new batch telecommunications claim version, the DME MAC shared system shall develop a current, in-use format skinny non-SFR claim format to accommodate those situations where COBA trading partners are unable to accept pharmacy -submitted claims in the NCPDP new version format.  In addition, the DME MAC shared system shall develop an NCPDP new version skinny non-SFR format that addresses the scenario of claims originally adjudicated in the  NCPDP current, in- use format and later adjusted after the NCPDP new version format is required in association with all incoming and outgoing NCPDP new version claims.  The DME MAC shared system shall also develop an NCPDP new version skinny non-SFR forma t that addresses the scenario of claims that a DME MAC originally adjudicated in the NCPDP current, in-use format but suspended for a period of time that meets or transcends the date by which the NCPDP new version format is required in association with all incoming and outgoing NCPDP new version claims.  II - NCPDP New Version  Mapping Requirements   With respect to the NCPDP new version COB flat file submissions to the Benefits Coordination & Recovery Center (BCRC), the ViPS Medicare System (VMS) maintainer shall observe the following business rules for mapping:  A. General   1. The 504-F4 (Message) Trailer portion of the file shall contain a 22-byte identifier populated as follows:  a.) Bytes 1 -9Contractor ID (9 bytes; DME MAC ID, or, 5 bytes left justified, followed by spaces);  b.) Bytes 10-14Julian Date (5 bytes, expressed as YYDDD);   c.) Bytes 15-19Sequence Number (5 bytes, starting with 00001; should increment for each ST -SE envelope);  d.) Bytes 20-21Claim Version Indicator (2 bytes; values= 20 for NCPDP version D.0 claims); and   e.) Byte 22Test/Production Indicator (1 byte; valid values=Ttest; P production).  B. Transmission/Transaction Header Segment   1. Create 101 -A1 (BIN assigned number) with spaces.   2. Create the claim version release number (102 -A2) within the Transmission/Transaction Header Segment.   3. Populate the appropriate transaction code (103-A3), the processor control number (104-A1), and transaction count value (109- A9).  4. Always map the service provider ID qualifier corresponding to the national provider identifier (NPI) in 202-B2.   5. Always map the suppliers NPI in 201- B1 (Service Provider ID).   6. Map date of service from incoming claim for 401- D1.  7. Map 110- AK (Software Vendor/Certification ID) from incoming claim.   IMPORTANT:    For skinny NCPDP current, in use claim scenarios, where the incoming claim is the current, in use version NCPDP, the shared system shall map unknown in 110- AK.  C. Trans mission Insurance Segment   1. Map the beneficiarys Medicare beneficiary identifier  in 302-C2 (Cardholder ID).   2. Map 312-CC and 313-CD (Cardholders First and Last Names) using information from the DME MACs internal eligibility file.   3. Do not cre ate 301 -C1 (Group ID), as CMS no longer authorizes claims- based transfers to Medicaid State Agencies.   4. Do not create 336-8C (Facility ID), even in skinny claim situations.  5. For Medigap claim -based crossover purposes only, the shared system shal l continue to populate the Medigap claim-based COBA ID (range 55000-55999) in the flat file field corresponding to 301-C1 (Group ID), as derived from the incoming claim.   In addition, the shared system shall populate the Medigap policy ID in the newly cre ated 359-2A (Medigap ID) element, as derived from the incoming claim.   6. Always map an A value for element 361 -2D (Provider Accept Assignment Indicator).   7. Do not  create elements 115 -N5, 116-N6, 314- CE, 303-C3, and 306-C6.   8. Create 524 -F0 (Plan ID) in the future only when CMS directs.  D. Transmission Patient Segment   1. Create element 331 -CX (Patient ID Qualifier) as appropriate.   2. Create 307 -C7 (Place o f Service) based upon the incoming claim.   3. Always map the beneficiarys Medicare beneficiary identifier in 332- CY (Patient ID).    4. Map elements 304 -C4, 305-C5, 310-CA, and 311- CB from the DME MACs internal beneficiary eligibility file.   5. Map el ements 322- CM, 323-CN, 324-CO, and 325- CP from the DME MACs internal beneficiary eligibility file.   (* --See Gap Filling Requirements in Attachment B to address situations where the beneficiarys line -1 address, as derived from the DME MACs internal bene ficiary eligibility file, is blank or incomplete.)  6. Map 326-CQ (Patient Phone Number) and 350- HN (Patient E -mail Address) from incoming claim.  ( Assumption:   CEDI will ensure these values are syntactically correct as a condition of inbound claim acceptance.)   7. Do not create element 335 -2C (Pregnancy Indicator) on the NCPDP new version COB file.  E. Transaction Prescriber Segment   1. Map element 466 -EZ (Prescriber ID Qualifier) from the incoming claim.   2. Always map 01 for element 468- 2E (Primary Care Provider ID Qualifier).   3. Map the NPI, as derived from the incoming claim, in element 421- DL (Primary Care Provider ID).   4. Map the suppliers name, as derived from the DME MACs internal provider files, for 470- 4E (Primary Care Provider Last Name).   5. Map 411- DB based upon adjudicated claim data.   6. Map 427- DR (Prescriber Last Name) and 364 -2J (Prescriber First Name) from the DME MACs internal supplier files.   7. Map 365- 2K (Prescriber Address), 366 -2M (Prescriber Ci ty), 367- 2N (Prescriber State), 368 -2P (Prescriber Zip), and 498- PM (Prescriber Phone Number) based upon the availability of these elements in the SFR.  (See Attachment B for special gap -filling requirements that will come into play for NCPDP skinny mapping.)  F. Transaction COB/Other Payments Segment   1. Map element 337 -4C from the incoming claim.    2. Prepare element 338 -5C to appropriately qualify deductible or co-insurance remaining.  (NOTE:  In the case of adjustment claims, where the DME MAC used 98 or 99 previously, the shared system shall populate the NCPDP new version equivalent qualifying value on the COB flat file.)  3. Map value 05 for element 339 -6C in relation to Medicares role as payer of the claim.   4. Map the DME MACs workload identifier (e.g., 16003) in element 340-7C.  5. Map the Internal Control Number (element 993-A7) as received from CEDI and as a result of claim adjudication.   6. Map the following out on the COB flat file only if received on the incoming claim:  4 43-E8, 341- HB, 342-HC, 431-DV, 471-5E, 472- 6E.  7. Create 353 -NR, 351-NP, and 352-NQ in terms of primary payers patient responsibility count, qualifier, and remaining amount, as applicable, or the patient responsibility count, qualifier, and remaining amount after Medicare.   8. Do not map 392-MU, 393-MV, and 394- MW, as these are not used for Medicare purposes.   9. Do not create any portion of the Transaction Workers Compensation Segment.  G. Transaction Claim Segment   1. Map 343-HD, 344- HF, and 345-HG based upon availability on the data on the incoming claim.   2. Create 455 -EM and 402-D2 as required, without gap- filling.   3. Create 403 -D3, 405- D5, 406-D6, and 407-D7 as required, without gap- filling.   4. Create all of the following if received on the incoming claim:  408-D8, 414- DE, 415-DF, 418-DI, 419-DJ, 420-DK, 453-EJ, 445-EA, 446-EB, and 457- EP. (NOTE:  Gap -filling of 453- EJ with spaces is acceptable if the shared system is also concurrently gap-filling 445- EA with spaces.)   5. Create procedure modifier count (458-SE) based upon claim adjudication.  6. Create procedure modifier code as appropriate.   7. Map 442-E7 and 426-E1 as required, without gap- filling.    8. Create 456 -EN, 420- DK, 308 -C8, and 429- DT to the COB file if received on the incoming claim.   9. Map 454-EK (now required in certain situations) and 600-2B if received on the incoming claim.   10. Do not create 461-EU, 462-EV, 463-EW, 464-EX, 354-NX, 357-NV, 995-E2, 996- G1, and 147-U7 if received on the incoming claim.  11. Always create 391 -MT (Patient Assignment Indicator) on the COB flat file.  (NOTE:  CEDI shall reject NCPDP claims with this element missing at the DME MACs front -end.)  H. Transaction Compound Segment