(Medicare Claims Processing Manual)

HIPAA Error Code  ICN Date (Date file was transmitted to the BCRC)             HIPAA Error Code(s)        Part A/Part B/NCPDP Claim     Technical Issue  (Claims file transmission failures)  File Name             Transmission Date         Summary of Issue - Provide detail of problem and note if back -up information will be faxed, e.g., Sample Claims to be Faxed on MM/DD/YR. Indicate whether you would like your issue on the next HIPAA issues log  do not include any PHI information on this form if sent via email.  All PHI information must be submitted via fax to the BCRC to the attention of your BCRC representative at 646-458-6761. Do not include PHI information on the fax cover sheet.  Claim examples of issues to be addressed must include the b eneficiary Medicare beneficiary identifier and the claim ICN/DCN.  BCRC USE ONLY.  Date:                                                                               Ticket #:   V.  Identification of Mass Adjustments for COBA Crossover Purposes   All A/B MACs and DME MACs and their shared systems shall develop a method for differentiating mass adjustments tied to the Medicare Physician Fee Schedule (MPFS) updates and all other mass adjustments from all other kinds of adjustments and non- adjustment claims.   NOTE:  For appropriate classification, all adjustments that do not represent mass adjustments -MPFS or mass adjustments -other shall be regarded as other adjustments.)  DME MACs and their shared system shall only be required to identify mass adjustments -other, which represents a current functionality available within VMS.  This is because DME MACs do not use pricing from the MPFS when processing their claims.  Working Definition of Mass Adjustment  For COBA crossover purposes, a mass adjustme nt refers to an action that an A/B MAC or DME MAC undertakes using special software (e.g., Super-Op Events or Express Adjustments) to pull together claims with the anticipated purpose of making monetary changes to a high number of those claims.  If, however, A/B MACs and DME MACs do not have special software to perform high volume adjustments (i.e., typically adjustments to 100 or more claims), but instead must perform their high volume adjustments manually, this action also fulfills the definition of a mass adjustment.  Inputting a One -Byte Header Value on Claim Transactions to Designate Mass Adjustment and Associated Processes   Before A/B MACs and DME MACs cable their claims to CWF for verification and validation, they shall populate a 1- byte mass adjustment indicator in the header of their HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC entry code 5 or action code 3 claim transactions.  The CWF maintainer shall create a new 1 -byte field within the header of its HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC clai ms transactions for this purpose.   A/ B MACs and DME MACs shall determine whether the M or O indicator applies in relation to a given claim at the point that they initiate a mass adjustment action on that claim using a manual process or an automated ad justment process; e.g., Super Op Events or Express Adjustments.  Upon making this determination, the A/B MACs and DME MACs and their shared systems shall populate one (1) of the following mass adjustment claim indicators, specific to the particular claim s ituation, within the header of the A/B MACs or DME MACs processed claims that they will cable to CWF for verification and validation:  Mif mass adjustment claim tied to an MPFS update; or  Oif mass adjustment claim-other.  If A/B MACs and DME MACs se nd values other than M or O within the newly designated field within the header of their HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC entry code 5 or action code 3 claims, CWF shall apply an edit to reject the claims back to the MAC.  Upon receipt of the CWF rejection edit, the shared systems shall correct the invalid value and retransmit the claims to CWF for verification and validation.  VI. Special ASC X12 835 Remittance Advice and MSN Requirements for Health Care Pre- Payment Plans (HCPPs) and Health Ma intenance Organization (HMO) Cost Plans that Receive Crossover Claims   Effective January 5, 2009, at CMSs direction, the BCRC assigned all COBA HCPP and HMO Cost Plan 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.  Upon receipt of a BOI reply trailer (29) that contains only a COBA ID in the range 89000 through 89999, the A/B MAC and DME MAC shared systems shall suppress all  crossover information (including name of the insurer; generic message; and specific code (for ASC X12 835, code MA-18; for MSN, code 35.1) indicating that the claim will be crossed over) from the associated ASC X12 835 remittance advice and beneficiary MSN.  (See 70.6.1 of this chapte r for A/B MAC or DME MAC requirements relating to the BCRC Detailed Error Report processes and receipt of claims that contain COBA ID range 89000 through 89999.)  VII. Special Suppression Requirements for Part A Credit Claim Portion of Debit -Credit Claim Pairing   Effective with the April 2009 release, the A/B MAC (Part A) and A/B MAC (Part HHH) shared system shall suppress sending the credit claim portion of the debit-credit pairing (that transaction which cancels the original claim) associated with each affiliated A/B MACs (A, HHH) adjustment claims to the BCRC.  Upon suppressing the credit claim, the A/B MAC (Part A) and A/B MAC (Part HHH) system shall mark the claims history of its affiliate MAC to reflect this action.   70.6.1 - Coordination of Benefits Agreement (COBA) Detailed Error Report Notification Process  (Rev. 11939; Issued:04-05- 23; Effective:07 -06-23, Implemtation:07-06-23)   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 fo r certain business areas that will continue to use the HICN as part of their processes.  Effective with the July 2005 release, CMS implemented an automated process to notify physicians/ practitioners, suppliers, and providers that specific claims that were previously tagged by the Common  Working File (CWF) for crossover will not be crossed over due to claim data errors.  Claims transmitted via ASC X12 837 flat file by the A/B MAC and DME MAC shared systems to the Benefits Coordination & Recovery Center (BCR C) may be rejected at the flat file level, at a HIPAA ASC X12 pre- edit validation level, or by trading partners as part of a financial dispute arising from an invoice received.   Effective with the April 2005 release, the A/B MAC and DME MAC shared systems began to populate the BHT 03 (Beginning of Hierarchical Reference Identification) portion of their ASC X12 837 COB flat file submissions to the BCRC with a unique 22- digit identifier.  This unique identifier will enable the BCRC to successfully tie a claim  that is rejected by the BCRC at the flat file or HIPAA ASC X12 pre -edit validation levels as well as claims disputed by trading partners back to the original ASC X12 837 flat file submissions.   Effective October 4, 2005, A/ B MACs and DME MACs and their s hared systems began to receive notification via the BCRC Detailed Error Reports, whose file layout structures appear below, that a COBA trading partner is in test or production mode via the BHT 03 identifier that is returned from the BCRC.   Effective April  3, 2011, all A/B MACs and DME MACs shall include an extra 1- byte Original versus Adjustment Claim Indicator value within the BHT03 identifier on all ASC X12 837 institutional and professional claims they transmit to the BCRC  for crossover purposes.  The  BCRC shall, in turn, return this value to the appropriate A/B MAC and DME MAC via the BCRC Detailed Error Report process. In addition, the DME MAC shared system shall send an additional 1- byte value (defined as reserved for future use) as spaces in fiel d 504- F4 (Message) of the NCPDP flat file sent to the BCRC.  The BCRC shall, in turn, also return this value to the appropriate DME MAC via the BCRC Detailed Error Report process.  Effective April 1, 2013, CMS added a new 1- byte Original versus Adjustment indicator to the suite of possible 1- byte options for position 23 of the BHT03 identifier, as reflected below.  Effective with April 7, 2014, CMS has added 2 new 1- byte Original versus Adjustment indicators to the suite of possible options for position 23 of the BHT03 identifier, as reflected below.  A.  Inclusion of the Unique 23 -Digit Identifier on the ASC X12 837 Flat File and NCPDP File   1. Populating the BHT 03 Portion of the ASC X12 837 Flat File   The A/B MAC and DME MAC shared systems shall p opulate the BHT 03 (Beginning of Hierarchical Transaction Reference Identification; field length=30 bytes ) portion of their ASC X12 837 flat files that are sent to the BCRC for crossover with a 23- digit Contractor Reference Identifier (CRI).  The identifie r shall be formatted as follows:   a. A/B MAC or DME MAC number (9 -bytes; until the 9 -digit MAC number is used, report the 5- digit MAC number, left -justified, with spaces for the remaining 4 positions);   b. Julian date as YYDDD (5 bytes);   c. Sequence number (5 bytes; this number begins with 00001, so the sequence number should increment for each ST -SE envelope, which is specific to a   trading partner, on a given Julian date);   d. Claim version indicator (2 bytes, numeric, to denote claim version)  **Acceptable values = 50 (for ASC X12 claims), and 20 (for NCPDP D.0 claims);   e. COBA Test/Production Indicator (1- byte alpha indicator; acceptable values = T [test] and P [production]) or R if the claims were recovered for a production COBA trading partner (see 70.6.3 of this chapter for more details;    f. Original versus Adjustment Claim Indicator (1 -byte alpha indicator); acceptable values are defined as the following:   E - for reprocessed claims that formerly included an electronic prescribing (e -RX) negative adjustment amount;   O - for original claims;  P - for Affordable Care Act or other congressional imperative mass adjustments;   M - for non- Affordable Care Act mass adjustments tied to Medicare Physician Fee Schedule (MPFS);   S - for mass adjustment claims all others;  R - for RAC adjustment claims ;    A - for routine adjustment claims, not previously classified; and  C  for CMS -directed mass adjustment action (use specified by CMS).   The following indicator is only applicable to FISS -gene rated claims:  V - Void/cancel only claim   The 23- digit CRI shall be left- justified in the BHT 03 segment of the 837 flat file, with spaces used for the remaining 8 positions.  ( NOTE:   The CRI is unique inasmuch as no two files should ever contain the same combination of numbers.)    2.  NCPDP 23 -Digit Unique Identifier   Effective April 3, 2011, the DME MAC shared system shall also adopt a unique 23- digit format, referenced directly above under Populating the BHT 03 Portion of the ASC X12 837 Flat File.  However, prior to April 7, 2014, the system shall populate the unique 23- digit identifier (defined as future use) with spaces in field 504- F4 (Message) within the NCPDP file (field length=35 bytes).  The DME MAC shared system shall populate the unique identifier, left justified, in the field.  Spaces shall be used for the remaining bytes in the field.