evekhm/cms_iom_500 huggingface dataset:
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 Suppress the claim from crossover if the COBA trading partner wishes to exclude either adjustments, monetary or adjustments, non- monetary, or both.  (NOTE:   The expectation is that such claims do not represent mass adjustments tied to the MPFS or mass adjustments -other.)   By Passing of Logic to Exclude Adjustment Claim if Original Claim was Not Crossed Over   For purposes of excluding entry code 1 or action code 1 claims that contain an A adjustment indicator value, CWF shall 1) assume that the original claim that was purged from its online history was crossed over, and 2) bypass its logic for crossover disposition indicator R (cross the adjustment claim over only if the original claim was previously crossed over).  Refer to 80.4 of this cha pter for further details regarding this logic.  Actions to Take When A/B MAC or DME MACs Send Invalid Values   If A/B MAC  or DME MAC  sends  claim adjustment indicator values other than N, A, or space within the newly designated header field within their HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims to CWF , CWF shall apply an edit to reject the claim back to the A/B MAC or DME MAC .  Upon receipt of the CWF rejection edit, the shared systems shall correct the invalid value and retransmit the claim to CWF fo r verification and validation.  Creation of a New Crossover Disposition Indicator For This Scenario  In relation to its receipt of a claim that has an A header value, the CWF shall create a new crossover disposition indicator Y (archived adjustment cl aim-excluded)  on the HIMR detailed history screens in association with excluded processed claims for production COBA trading partners.  The CWF shall display the new Y crossover disposition indicator in association with the processed mass adjustment c laim- MPFS on the HIMR detailed history screen.  (See 80.5 of this chapter for further information.)   Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF Beneficiary Other Insurance (BOI) Reply Trailer 29
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Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF Beneficiary Other Insurance (BOI) Reply Trailer 29   If A/B MACs  or DME MACs  receive a BOI reply trailer (29) on a claim that had an A indicator set in its header, the A/B MAC or DME MACs  systems shall ensure that, as part of their 837 flat file creation processes, they populate the 2300 loop CLM05- 3 (Claim Frequency Type Code) segmen t with a value that designates adjustment rather than original to match the 2330B loop REF*T4*Y that they create to designate adjustment claim.   If a given shared system does not presently create a loop 2330B REF*T4*Y to designate adjustments, it sha ll not make a change to do so as part of this instruction.    80.7 - Coordination of Benefits Agreement (COBA) Medigap Claim -Based Crossover Process  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  Effective with claims submitted to Medicare on October 1, 2007, and after, participating physicians and suppliers will be expected to include a 5 byte COBA identifier (range 55000---55999) on incoming crossover claims for purposes of triggering claim -based Medigap crossovers.  Additionally, effective with October 1, 2007, claim -based Medigap crossovers will occur exclusively through the BCRC in the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12- N 837 professional clai m format (current version) and National Council for Prescription Drug Programs (NCPDP) claim format.  A.  Changes to A/B MAC or DME MAC Up -Front Screening Processes for COBA Claim -based Medigap Crossovers
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Effective with claims that the A/B MACs (B) and DME MACs will cable to CWF on October 1, 2007, their internal processes for screening claims for Medigap claim -based crossovers shall be modified to accommodate the new Medigap claim -based COBA crossover proc ess.  The affected A/B MACs (B) and DME MACs processes for screening claims for Medigap claim -based crossovers shall now feature a syntactic editing of the incoming COBA claim -based Medigap ID to ensure that the identifier begins with a 5 and contains 5 numeric digits.  In addition, for incoming 837 professional and NCPDP claims, A/B MACs (B) and DME MACs shall ensure that the Medigap claim -based COBA ID is entered within the appropriately designated field, loop, or segment of the incoming Medicare claim .  If the claim fails the syntactic verification, the A/B MAC (B) or MAC shall not copy the identifier from the incoming claim and populate it within field 34 (Crossover ID) of the HUBC or HUDC claim transaction that is sent to the CWF for verification a nd validation.  Instead, the A/B MAC (B) or DME MACs shall continue to follow its pre -existing processes for notifying the provider via the ERA or other remittance advice and the beneficiary via the MSN that the information reported did not result in the c laim being crossed over.  The affected A/B MACs (B) or DME MACs screening processes for Medigap claim -based crossovers shall also continue to include verification that the provider participates with Medicare and that the beneficiary has assigned benefits to the provider.
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If the provider -populated value for the Medigap claim -based ID passes the A/B MAC (B) or DME MACs syntactic editing process, the affected A/B MAC or DME MACs systems shall copy the Medigap claim -based COBA ID value from the incoming cla im to field 34 of the HUBC or HUDC claims transactions that are sent to CWF for verification and validation.  The A/B MACs (B) and DME MACs shall populate the identifier in field 34 right -justified and prefixed with five zeroes.   B.  CWF Validation of Valu es within Field 34 of the HUBC and HUDC Transactions   Upon receipt of HUBC and HUDC claims that contain a value within field 34 (Crossover ID), the CWF shall read the value that is present within the field for purposes of conducting a validity check.  The CWF shall accept the following values as valid within field 34:  a value within the range of 0000055000 to 0000059999, or spaces.   If the A/B MAC (B) or DME MAC has sent an inappropriate value in field 34 of the HUBC and HUDC claims transaction, CWF shal l return an alert code 7704 on the 01 disposition response via the claim -based alert trailer 21.   For customer service purposes, the CWF maintainer shall create a new crossover disposition indicator Z to accommodate the scenario of the A/B MAC (B) or DME MAC sending an incorrect value within field 34 of the HUBC and HUDC transaction.  (See 80.5 of this chapter for more information regarding this crossover disposition indicator.)  At the point that CWF returns an alert code 7704 to the affected A/B MAC  (B) or DME MAC, it shall take the following actions with respect to the claim:  1.  Mark the claim with crossover disposition indicator Z (invalid Medigap claim -based crossover ID included on the claim); and  2.   Display the indicator, together with the invalid COBA ID value from field 34, in association with the claim on the appropriate HIMR detailed history screen in the claim -based crossover segment.
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See Pub.100- 04 chapter 28, 70.6.4 for an explanation of A/B MAC or DME MAC processes following receipt of a CWF alert code 7704 via a 21 trailer.   C.  CWF Processing for COBA Claim-based Medigap Crossovers  Following receipt of an HUBC and HUDC claims transaction that contains a valid value within field 34 (a value within the range of 0000055000 to 0000059999 or spaces), CWF shall check for the presence of a BOI auxiliary record for the purpose of triggering eligibility file -based crossovers.  CWF shall then read the COIF to determine the claims selection criteria for any eligibility file -based tradi ng partners (all other COBA IDs) as well as for the Medigap claim -based insurer (range 0000055000 to 0000059999).  If the HUBC or HUDC claim contains a valid COBA Medigap claim-based ID within field 34 but the valid ID cannot be found on the COIF, the CWF shall post the valid COBA Medigap claim -based ID without an accompanying crossover disposition indicator in association with the claim within the claim-based crossover segment of the appropriate HIMR claim detailed history screen.   If the claim meets the  COBA trading partners selection criteria, as per the COIF, and none of the other scenarios presented below applies, CWF shall return a Beneficiary Other Insurance (BOI) reply trailer (29) to the A/B MAC (Part B) or DME MAC for purposes of having the A/B MAC (B) or DME MAC trigger a crossover to the BCRC.   Duplicate Check
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Duplicate Check   The CWF shall perform a duplicate check to determine if the beneficiary is identified for crossover to a Medigap eligibility file-based insurer (COBA ID 30000-54999) and to a Medigap claim-based insurer (COBA ID 0000055000-0000059999).  If CWF determines that the beneficiary is identified for crossover to both a production Medigap eligibility file-based insurer (COBA ID range=30000 to 54999) and a Medigap claim- based Medigap insurer (COBA ID range=0000055000 to 0000059999), it shall suppress the BOI reply trailer (29) for the claim-based Medigap insurer (COBA ID range= 0000055000 to 0000059999).  Crossover Disposition Indicator AA  Effective with October 1, 2007, the CWF maintainer created a new crossover disposition indicator AA to accommodate the CWF duplicate check, where it has determined that the beneficiarys claim is eligible for crossover to both a production Medigap eligibility file-based insurer and  a Medigap claim -based crossover insurer.  After CWF has determined that beneficiary has already been identified for Medigap eligibility file- based crossover, it shall take the following actions with respect to the claim:   1.  Mark the associated claim with indicator AA (beneficiary identified on Medigap insurer eligibility file; duplicate Medigap claim-based crossover voided); and   2.  Display this indicator, together with the affected claim- based Medigap COBA ID, in association with the claim on the appropriate HIMR detailed history screen in the claim -based crossover segment.  D.  BOI Reply Trailer (29) Process
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D.  BOI Reply Trailer (29) Process   If CWF determines that the claim meets the trading partners claims selection criteria, it shall select the claim and return a BOI reply trailer 29 for the claim to the affected A/B MAC (B) or DME MAC.  The CWF shall display the appropriate crossover disposition indicator for the claim- based crossover claim within the claim- based crossover segment of the HIMR claim detailed history screens.  As with the COBA eligibility file -based crossover process (see 80.4 of this chapter for more details regarding this process), CWF shall display the COBA ID and accompanying crossover disposition indicator on claim detailed  history screens, with the exception of circumstances where the valid ID cannot be located on the COIF, as discussed above, or the Medigap claim -based insurer is in test mode with the BCRC.  In these situations, only the COBA Medigap claim -based ID shall  be displayed.   Modification of the CWF Sort Routine For Multiple COBA IDs and Accompanying A/B MAC or DME MAC Actions Following Receipt of the BOI Reply Trailer (29)   In light of the new COBA Medigap claim -based crossover process, the CWF sort routine for COBA IDs to be returned via the BOI reply 29 trailer shall be modified as follows:  Medigap eligibility file -based (30000- 54999), Medigap claim -based (55000- 59999), supplemental (00001- 29999), TRICARE for Life (60000- 69999), Other insurer (80000 -89999), a nd Medicaid (70000- 79999).  (NOTE:  This information is also being updated in 80.4 of this chapter)
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Upon receipt of the BOI reply trailer (29), the affected A/B MAC (B) or DME MAC shall continue to utilize information from this source to populate the beneficiarys MSN and provider ERA or other remittance advice in production in accordance with the existing guidance that appears in 80.4 of this chapter. 80.8 -  Inclusion and Exclusion of Specified Categories of Adjustment Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  1. CWF Inclusion of Adjustment Claims   Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion  of adjustment claims option, along with 1 -byte file displacement, within its version of the COIF; and 2) accept and process this new field when the BCRC transmits it as part of its regular COIF updates.   Upon receipt of a COIF that features a COBA identification number (ID) with specifications to include adjustment claims only, the CWF shall select only those claims for COBA crossover that meet the following specifications:   1) The claims action code=3, entry code=5, or claim adjustment indicator=A all of which designate an adjustment claim; and   2) The claim meets no other exclusion criteria, as specified on the COIF, or  does not meet the NPI placeholder value by-pass exclusion logic.  With the implementation of this change, the CWF shall continue to select adjustment claims only if it previously selected the original claim for crossover (logic for adjustment indicator R; see 80.4 of this chapter for additional details regarding this logic).  If the incoming HUIP, 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 specified on the COIF.   2.  CWF Inclusion of Two Categories of Mass Adjustment Claims for Crossover Purposes
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2.  CWF Inclusion of Two Categories of Mass Adjustment Claims for Crossover Purposes   Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion of mass adjustment claims MPFS updates and mass a djustment claims other options, along with accompanying 1- byte file displacement indicators, 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.  Upon receipt of a HUI P, HUOP, HUHH, HUHC, HUBC, or HUDC claim transaction, CWF shall take the following actions:  1) Verify that the claim transaction contains an M or O mass adjustment claim header indicator; 2) verify that the claims action code=3, or entry code=5, or adjustment header indicator=A; 3) check the COIF to determine if the COBA trading partner wishes to include mass adjustment claims MPFS or mass adjustment claims --other; 4) include the claim for crossover, unless the original claim was not  crossed over (l ogic for crossover disposition indicator R) or the claim meets any claims exclusion criteria as specified on the COIF.   If the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the mass adjustment indicator field, CWF shall select the claim per the COBA trading partners claims selection criteria, as specified on the COIF.   3.  CWF Inclusion and Exclusion of Recovery Audit A/B MAC or DME MAC (RAC)-Initiated Adjustment Claims   At CMSs direction, the BCRC has modified the COIF to allow for the unique inclusion  and exclusion of RAC- initiated adjustment claims.  The CWF system shall 1) create the newly defined inclusion and exclusion of RAC -initiated adjustment options, along with  accompanying 1-byte file displacement, on 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.  Effective January 5, 2009, the CWF maintainer created a 1 -byte RAC adjustment value in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions (valid values= R or spaces.)
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The CWF maintainer shall, in addition, include the 1- byte RAC adjustment indicator in the header of the claim that is posted to history on HIMR, thereby ensuring that CWF displays the indicator when a user accesses the INPH, OUTH, PTBH, DMEH, and related HIMR screens.    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
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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.)
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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
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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.
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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)