evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.   Effective April 7, 2014, the DME MAC shared system shall ensure that its DME MACs have the ability to 1) execute actions that will result in the tr ansmission of their HUDC claims to CWF with Mass Adjustment Indicator set to O; and 2) transmit mass adjusted NCPDP D.0 COB claims to the BCRC under a 504- F04 (Message) field identifier of "C" (CMS -directed mass adjustment action) or "P" (mass adjustments tied to Affordable Care Act or Congressional/legislative mandate) as appropriate to the situation.  In addition, the DME MAC shared system shall ensure that all NCPDP D.0 crossover claims will now be sent to the BCRC with the 23rd byte 504- F04 (Message) field indicator completed, when appropriate, as indicated below.    O -- for all "original" NCPDP D.0 claims transmitted;   A-- for "routine adjustment claims" transmitted; and    R-- for recovery audit claims (RAC) adjustment claims transmitted.
(Medicare Claims Processing Manual)
O -- for all "original" NCPDP D.0 claims transmitted;   A-- for "routine adjustment claims" transmitted; and    R-- for recovery audit claims (RAC) adjustment claims transmitted.   B.  BCRC I nstitutional, Professional, and NCPDP Detailed Error Reports    The A/B MAC and DME MAC shared systems shall accept the BCRC Institutional, Professional, and NCPDP Detailed Error Reports received from the COB&R system supporting the BCRC.    Effective with A pril 5, 2021, the datasets that the COB&R system supporting BCRC will use to convey the BCRC Detailed Error Reports to the VDCs representing the MACs are as follows:   xxxx.FISP.HBADR.GHI.COB5ERR(+1)   [For Institutional Claims]  xxxx.MCSP.HBXDR.ADyy5ERC(+1)  [For Professional non- DMEPOS Claims]  xxxx.VMSP.COBC.A5010.ERROR.FILE(+1)   [For Professional DMEPOS Claims]    The formats for each of the Detailed Error Reports appear below.   Beginning with July 2007, all A/B MAC and DME MAC systems shall no longer interpret the percentage values received for ASC X12 837 institutional and professional claim 222 and 333 errors via the BCRC Detailed Error Reports as if the values contained a 1 -position implied decimal (e.g., 038 =3.8 percent).  DME MACs shall also no longer interpret the percentage values received for NCPDP claims for 333 errors via the BCRC Detailed Error Report for such claims as if the values should contain a 1 -position implied decimal.   In addition, A/B MACs and their systems shall now base their decision -making calculus for initiation of a claims repair of 111 (flat file) errors upon the number of errors received rather than upon an established percent parameter, as otherwise described within this section.
(Medicare Claims Processing Manual)
Effective with July 2009, the A/ B MAC and DME MAC shared systems shall accept the modified versions of the BCRC Detailed Error Reports for institutional and professional claims as reflected below.  As part of the July 2009 changes, the BCRC will, at CMSs direction, expand the length of the error description field. ( NOTE:   This means that the shared systems shall therefore include the expanded error description code as part of their special provider notification letters.)      The Institutional Error File Layout, including summary portion, will be used for Part A claim files.                                                               BCRC Detailed Error Report                                              Institutional Error File Layout -  (Detail Record)   Field  Description  Field Size  Reco rd Location  1 Date  8 1-8 2 Control Number  9 9-17 3 COBA ID  10 18-27 4 Subscriber ID/Medicare ID  12 28-39 5 Claim DCN/ICN  14 40-53 6 Record Number  9 54-62 7 Record/Loop Identifier  6 63-68 8 Segment  3 69-71 9 Element  2 72-73 10 Error Source Code  3 74-76 ('111', '222', or '333')  11 Error/Trading Partner Dispute Code  6 77-82 12 Filler  100 83-182 13 Field Contents  50 183-232 14 BHT 03 Identifier  30 233-262 (23 bytes used)  15 Claim DCN/ICN  23 263-285  Field  Description  Field Size  Reco rd Location  16 Error Description  300 286-585 17 Filler  15 586-600                                           Institutional Error File Layout -  (Summary Record)   Field  Description  Field Size  Record Location  1 Date  8 1-8 2 Total Number of Claims for Processing Date  10 9-18 3 Number of '111' Errors  10 19-28 4 Number of '222' Errors  10 29-38 5 Percentage of '222' Errors  3 39-41 6 Number of '333' Errors  10 42-51 7 Percentage of '333' Errors  3 52-54 8 Filler  19 55-73 9 Summary Record ID Error Source Code  3 74-76 ('999')  10 Filler  524 77-600  The Professional Error File Layout, including summary portion, will be used for Part B and DME MAC claim files.   BCRC Detailed Error Report
(Medicare Claims Processing Manual)
The Professional Error File Layout, including summary portion, will be used for Part B and DME MAC claim files.   BCRC Detailed Error Report   Professional Error File Layout -  (Detail Record)  Field  Description  Field Size  Record Location  1 Date  8 1-8 2 Control Number  9 9-17 3 COBA ID  10 18-27 4 Subscriber ID/Medicare ID  12 28-39 5 Claim DCN/ICN  14 40-53 6 Record Number  9 54-62 7 Record/Loop Identifier  6 63-68 8 Segment  3 69-71 9 Element  2 72-73 10 Error Source Code  3 74-76 ('111', '222', '333')  11 Error/Trading Partner Dispute Code  6 77-82 12 Filler  100 83-182 13 Field Contents  50 183-232 14 BHT 03 Identifier  30 233-262 (23 bytes used)  15 Claims DCN/ICN  23 263-285 16 Error Description  300 286-858 17 Filler  15 586-600  Professional Error File Layout  (Summary Record)   Field  Description  Field Size  Record Location  1 Date  8 1-8 2 Total Number of Claims for Processing Date  10 9-18 3 Number of '111' Errors  10 19-28 4 Number of '222' Errors  10 29-38 5 Percentage of '222' Errors  3 39-41 6 Number of '333' Errors  10 42-51 7 Percentage of '333' Errors  3 52-54 8 Filler  19 55-73 9 Summary Record ID Error Source Code  3 74-76 ('999')  10 Filler  524 77-600  The NCPDP Error File Layout, including summary portion, will be used by DME MACs for Prescription Drug Claims   BCRC Detailed Error Report    NCPDP Error File Layout -  (Detail Record)  Field  Description  Field Size  Record Location  1 Date  8 1-8 2 Batch Number  7 9-15 3 COBA ID  5 16-20 4 Medicare ID  12 21-32 5 CCN  14 33-46 6 Record Number  9 47-55 7 Batch Record Type  2 56-57 8 Segment ID  2 58-59 9 Error Source Code  3 60-62 ('111', or '333')  10 Error/Trading Partner Dispute Code  6 63-68 11 Error Description  100 69-168 12 Field Contents  50 169-218 13 Unique File Identifier  30 219-248 (23 bytes used)  14 CCN  23 249-271 15 Filler  18 272-289
(Medicare Claims Processing Manual)
NCPDP Error File Layout - (Summary Record)   Field  Description  Field Size  Record Location  1 Date  8 1-8 2 Total Number of Claims for Processing Date  10 9-18 3 Number of '111' Errors  10 19-28 4 Number of '333' Errors  10 29-38 5 Percentage of '333' Errors  3 39-41 6 Filler  18 42-59 7 Summary Record ID Error Source Code  3 60-62 ('999')  10 Filler  524 63-289    If the BCRC has rejected back to the A/B MAC and DME MAC shared system for 2 or more COBA Identification Numbers (IDs), the shared system shall receive a separate error record for each COBA ID.  Also, if a file submission from a shared system to the BCRC contains multiple  provider, subscriber, or patient level errors for one COBA ID, the shared system will receive a separate error record for each provider, subscriber, or patient portion of the file on which errors were found.  C.  Further Requirements of the COBA Detailed Error Report Notification Process   1.  Error Source Code   A/B MACs and DME MACs, or their shared systems, shall use all information supplied in the BCRC Detailed Error Report (particularly error source codes provided in Field 10 of Attachment B) to (1) ide ntify shared system changes necessary to prevent future errors in test mode or production mode (Test/Production Indicator= T or P) and (2) to notify physicians, suppliers, and providers that claims with the error source codes 111, 222, and 333 will not be crossed over to the COBA trading partner.   2.  Time Frames for Notification of All MACs Financial Management Staff and Providers   A/B MACs and DME MACs, or their shared systems, shall provide notification to MAC financial management staff for purpose s of maintaining an effective reconciliation of crossover fee/ complementary credits received within five (5) business days of receipt of the BCRC Detailed Error Report.
(Medicare Claims Processing Manual)
Effective with the October 2005 release, A/B MACs and DME MACs and their shared syste ms shall receive BCRC Detailed Error Reports that contain BHT03 identifiers that indicate T (test) or P (production)  status for purposes of fulfilling the provider notification requirements.  ( Note:   The T or the P portion of the BHT03 indicator will be identical to the Test/Production indicator originally returned from CWF on the processed claim.)   a) Special Automated Provider Correspondence  A/B MACs and DME MACs, or their shared systems, shall also take the following actions indicated below only when they determine via the Beneficiary Other Insurance (BOI) reply trailer (29) that a COBA trading partner is in crossover production mode with the BCRC (Test/Production Indicator=P).  After an A/B MAC or DME MAC, or its shared system, has received a BCRC Detailed Error Report that contains claims with error source codes of 111 (flat file error), 222 (HIPAA ASC X12 error), or 333 (trading partn er dispute), it shall take the following two specified actions within five (5) business days:
(Medicare Claims Processing Manual)
1. Notify the physician/practitioner, supplier, or provider via automated letter  or other electronic or automated method that the claim did not cross over.  The let ter or report/notification  shall include specific claim information, not limited to, Internal Control Number (ICN)/Document Control Number (DCN), Medicare beneficiary identifier , Medical Record Number (for Part A only), Patient Control Number (only if it i s contained in the claim), beneficiary name, date of service, and the date claim was processed.  2. Effective with July 2007, A/B MACs and DME MACs and their systems shall ensure that, in addition to the standard letter language (the claim(s) was/were not cros sed over due to claim data errors and was/were rejected by the supplemental insurer), their A/B MACs and DME MACs special provider letters or  reports /notifications , which are generated for 222 and 333 error rejections in accordance with CR 4277, now include the following additional elements, as derived from the BCRC Detailed Error Report:  1) HIPAA H -series rejection code or other rejection code, and 2) the rejection codes accompanying description.  NOTE:   A/B MACs or DME MACs, or their shared system s, are not  required to reference the COBA trading partners name on the above described automated letter or report/notification , since the original remittance advice (RA)/electronic remittance advice (ERA) would have listed that information, if appropriate.  2.  Update its claims history to reflect that the claim(s) did not cross over as a result of the generation of the automated letter or report.
(Medicare Claims Processing Manual)
Effective with October 1, 2007, all A/B MACs and DME MACs shall modify their special provider notification le tters that are generated for 111, 222, and 333 error situations to include the following standard language within the opening paragraph of their letters or reports: This claim(s) was/were not crossed over due to claim data errors or was/were rejected by the supplemental insurer.  A/B MACs and DME MACs shall reformat their provider notification letters or reports  to ensure that, in addition to the new standard letter language, they continue to include the rejection code and accompanying description, as derived from the BCRC Detailed Error Report, for 222 or 333 errors in association with each errored claim.   Effective with the July 7, 2009, release, upon receipt of the BCRC Detailed Error Report (DER), the A/B MAC (A) and A/B MAC (HH) shared syst em shall configure the existing 114 report, as derived from the BCRC DER, so that it : 1) continues to display in landscape format; and 2) includes a cover page that contains the providers correspondence mailing address.  b) Special Exemption from Generati ng Provider Notification Letters /Reports
(Medicare Claims Processing Manual)
Effective July 7, 2008, upon their receipt of BCRC Detailed Error Reports that contain 222 error codes 000100 (Claim is contained within a BHT envelope previously crossed; claim rejected) and 00010 (Duplicate claim; duplicate ST- SE detected), all shared systems shall automatically suppress generation of the special provider notification letters or reports/notifications  that they would normally generate for their associated A/B MACs and DME MACs in accordance with the requirements of this section as well as 70.6.3 of this chapter.  In addition, upon receipt of BCRC Detailed Error Reports that contain 333 (trading partner dispute) error code 000100 (duplicate claim) or 000110 (duplicate ISA-IEA) or 000120 (duplicate ST- SE), all shared systems shall automatically suppress generation of the special provider notification letters or reports/notifications , as would normally be required in accordance with this section as well as 70.6.3 of this chapter.  NOTE:   When suppressing their provider notification le tters or reports/notifications  for the foregoing qualified situations, the A/B MACs and DME MACs shall also not update their claims histories to reflect the non -crossing over of the associated claims.   A/B MACs and DME MACs should, however, continue to account for  the volume of claims that they are suppressing for financial reconciliation purposes.  Effective with October 6, 2008, when the BCRC returns the 222 error code N22225 to A/B MACs and DME MACs via the BCRC Detailed Error Report, the A/B MACs and DME MACs shared systems shall suppress generation of the special provider notification letters or reports/notifications  that they would normally issue in accordance with CRs 3709 and 5472.  When suppressing their provider notification letters or reports/notifications  following their receipt of a N22225 error code, the A/B MACs and DME MACs shared systems shall also not update their claims histories to reflect the non -crossing over of the associated claims.  A/B MACs and DME MACs should, however, continue to account for  the volume of claims that they are suppressing for financial reconciliation purposes.
(Medicare Claims Processing Manual)
Effective with January 5, 2009, when the BCRC returns claims on the BCRC Detailed Error Report whose COBA ID falls in the range 89000 through 89999 (range designates Other -Health Care Pre-payment Plan [HCPP] and HMO Cost Plan), the A/B MACs and DME MACs systems shall take the following actions:  1)  Suppress generation of the special provider letters or reports/notifications ; and   2)  Not updat e their affiliated A/B MACs and DME MACs claims histories to indicate that the BCRC will not  be crossing the affected claims over.    70.6.1.1 - Coordination of Benefits Agreement (COBA) ASC X12 837 5010 Coordination of Benefits (COB) Flat File Errors  (Rev. 3714, Issued: 02- 03-17; Effective: 07 -01-17; Implementation: 07 -03-17)  Effective with the implementation of the Health Insurance Portability and Accountability Act (HIPAA) ASC X12 837 5010 COB requirements, the BCRC  will return the error codes shown in the chart below to all A/B MACs and DME MACs whose flat file submissions lack structural elements necessary for the building of outbound HIPAA compliant crossover claims.   The shared systems shall, in addition, make modifications to any 111 error tables that they maintain, in accordance with the following charts, only in association with ASC X12 837 5010 COB flat files.  BCRC DETAILED ERROR REPORT 111 ERROR CRITERIA FOR 837 VERSION 5010  INSTITUTIONAL COB CLAIMS
(Medicare Claims Processing Manual)
Error Code  Error Description  Control # COBA ID Medicare ID CCN  Loop ID Segment  Element  Content  BHT 03 Reject Level  100 No ST Segment  NO NO NO NO NO YES  NO NO NO HEAD  101 No BHT Segment  YES  NO NO NO NO YES  NO NO NO HEAD  103 Missing 1000A Records  YES  NO NO NO YES  YES  NO NO YES  HEAD  104 Missing 1000B Records  YES  NO NO NO YES  YES  NO NO YES  HEAD  105 Invalid 1000A.NM109 YES  NO NO NO YES  YES  YES  YES  YES  HEAD  110 Invalid 1000B.NM103 YES  NO NO NO YES  YES  YES  YES  YES  HEAD  115 Invalid 1000B.NM109 YES  YES  NO NO YES  YES  YES  YES  YES  HEAD  120 Multiple 1000A per ST/SE  YES  NO NO NO YES  YES  NO NO YES  HEAD  125 Multiple 1000B per ST/SE  YES  NO NO NO YES  YES  NO NO YES  HEAD   Error Code  Error Description  Control # COBA ID Medicare ID CCN  Loop ID Segment  Element  Content  BHT 03 Reject Level  199 All 2000B Rejected  YES  YES  NO NO YES  YES  NO NO YES  HEAD  200 Missing 2000A  YES  YES  NO NO YES  YES  NO NO YES  PROV 201 Missing 2010AA  YES  YES  NO NO YES  YES  NO NO YES  PROV 210 Multiple 2010AA per 2000A  YES  YES  NO NO YES  YES  NO NO YES  PROV 211 Multiple 2010AB per 2000A  YES  YES  NO NO YES  YES  NO NO YES  PROV 212 Invalid presence of 2010AC per 2000A  YES  YES  NO NO YES  YES  NO NO YES  PROV 300 Missing 2000B  YES  YES  NO NO YES  YES  NO NO YES  SUB  301 Missing 2010BA  YES  YES  NO NO YES  YES  NO NO YES  SUB  302 Missing 2010BB Loop YES  YES  YES  NO YES  YES  NO NO YES  SUB  305 Multiple 2010BB per 2000B  YES  YES  YES  NO YES  YES  NO NO YES  SUB  306 Multiple 2010BA per 2000B  YES  YES  YES  NO YES  YES       NO NO YES      SUB  310 2010BB.NM109 not equal 1000B.NM109 YES  YES  YES  NO YES  YES  YES  YES  YES  SUB   Error Code  Error Description  Control # COBA ID Medicare ID CCN  Loop ID Segment  Element  Content  BHT 03 Reject Level  320 2010BB.N3 not equal spaces  YES  YES  YES  NO YES  YES  YES  YES  YES  SUB  321 2010BB.N4 not equal spaces  YES  YES  YES  NO YES  YES  YES  YES  YES  SUB  351 More than 100 2300 per 2000B  YES  YES  YES  NO YES  YES  NO NO YES  SUB  355 2300 REF01 Equal F5 Missing  YES  YES  YES  NO YES  YES  NO NO  YES  SUB  356 2300