evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The CWF shall modify its current logic for excluding Part A original Medicare claims paid at greater than 100 percent of the submitted charges as follows:  In addition to meeting the CWF exclusion criteria for Part A claims paid at greater than 100 percent of the submitted charges, CWF shall exclude these claims only when there is no deductible or co-insurance amounts remaining on the claims.   NOTE :  The current CWF logic for excluding Part B original Medicare claims paid at greater than 100 percent of the submitted charges/allowed amount (specifically, type F ambulatory surgical center claims, which typically carry deductible a nd co -insurance amounts) shall remain unchanged.  G.  Claims with Monetary or Non-Monetary Changes  The CWF shall check the reimbursement amount as well as the deductible and co -insurance amounts on each claim to determine whether a monetary adjustment change to an original Part A, B, or DM EPOS  claim occurred.   To exclude non-monetary adjustments for Part A, B, and DME POS claims, the CWF shall check the reimbursement amount as well as the deductible and co -insurance amounts on each claim to confirm that there were no monetary changes on the adjustment claim as compared to the original claim.   Effective with April 1, 2008, the CWF shall also include total submitted/billed charges as part of the foregoing elements used to exclude adjustment claims, monetary as well as adjustment claims, non -monetary.  (See sub-section N, Overarching Adjustment Claim Exclusion Logic, for details concerning the processes that CWF shall follow when the COBA trading partners COIF specifies exclusion of all  adjustment claims.)   H.  Excluding Adjustment Claims When the Original Claim Was Also Excluded  When the CWF processes an adjustment claim, it shall take the following action when the COIF indicates that the production COBA trading partner wishes to receive adjustment claims, monetary or adjustment claims, non -monetary:   Return a BOI reply trailer 29 to the A/B MAC or DME MAC  if CWF locates the original claim that was marked with an A crossover disposition indicator or if the original claims crossover disposition indicator was blank/non- existent;
(Medicare Claims Processing Manual)
 Exclude the adjustment claim if CWF locates the original claim and it was marked with a crossover disposition indicator other than A, meaning that the original claim was excluded from the COBA crossover process.  CWF shall not be required to search archived or purged claims history to determine whether an original claim had been crossed over.   The CWF maintainer shall create a new R crossover disposition indicator, as referenced in a chart within 80.5 of this chapter, to address this exclusion for customer service purposes.  The CWF maintainer shall ensure that adjustment claims that were excl uded because the original claim was not crossed over shall be marked with an R crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.   I.  Excluding Part  A, B, and DME MAC Fully Paid Adjustment Claims Without Deductible and Co -Insurance Remaining   The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) adjustment claims (identified as action code 3 for Part A claims and entry code 5 for Part B and DM EPOS  claims) when the COIF indicates that a COBA trading partner wishes to exclude adjustment claims that are fully paid and without deductible or co-insurance amounts remaining.  Effective with October 1, 2007, CWF develope d logic as foll ows to exclude fully paid Part A adjustment claims without deductible and co -insurance remaining:   1) Verify that the claim contains action code 3;  2) Verify that there are no deductible and co -insurance amounts on the claim;  3) Verify that the reimbursement on the claim is greater than zero; and  4) Confirm that the claim contains no denied services or service lines.   Special Note:   Effective with October 1, 2007, CWF ceased  by-passing the logic to exclude Part A adjustments claims fully (100 per cent) paid in association with home health prospective payment system (HHPPS) types of bills 329 and 339.  The CWF shall exclude such claims if the COIF designates that the trading partner wishes to exclude adjustment claims fully paid without deductible or co -insurance remaining or if these bill types are otherwise excluded on the COIF.   The CWF shall develop logic as follows to exclude Part B or DME POS fully paid adjustment claims without deductible or co -insurance remaining:
(Medicare Claims Processing Manual)
The CWF shall develop logic as follows to exclude Part B or DME POS fully paid adjustment claims without deductible or co -insurance remaining:   1) Verify that the claim contains an entry code 5;  2) Verify that the allowed amount equals the reimbursement amount; and  3) Confirm that the claim contains no denied services or service lines.   The CWF maintainer shall create a new S crossover disposition indicator for adjustment claims that are paid at 100 percent.  The CWF maintainer shall ensure that excluded adjustment claims that are paid at 100 percent shall be marked with an S crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add Adj. Claims -100 percent PD to the COBA Insurance File Summary screen (COBS) on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  Claims with Fully Paid Lines, without Deductible or Co -insurance Remaining, and Additional Denied Service Lines   New HUBC Line -Level Indicator Field   Effective January 4, 2010, the CWF maintainer create d a new 1 -byte LIAB IND at the service line level for individually denied claim lines  in association with the HUBC claim transaction (valid values=B or spaces).  Part B Shared System Requirements   When the Part B shared system adjudicates adjustment claims where most of the claim service detail lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line that are the same as the paid amounts per line and the lines do not carry deductible or co -insurance amounts) but where some detail lines are denied, it shall take the following actions:   1) Input a B value in the newly created 1 -byte LIAB IND field for each denied service line where the beneficiary has payment liability ( NOTE:   there may be multiple instances where the B value will be applied, contingent upon whether the beneficiary is liable for each of the denied service lines);   2) Input spaces in the newly created 1-byte LIAB IND field for each denied service line where the provider, rather than the beneficiary, is contractually liable for the denied service; and  3) Transmit the HUBC claim to CWF for normal verification a nd validation processing.  CWF Requirements
(Medicare Claims Processing Manual)
CWF Requirements   The CWF system shall modify its logic for adjustment fully paid claims, without deductible or co- insurance remaining, in association with Part B HUBC claims as follows:  1) Continue to verify the claims entry or action code for confirmation that the claim is an adjustment;  2) Where applicable, also continue to check additionally to determine if the incoming claim contains entry code 5 or  an R recovery audit contractor (RAC) adjustment indicator, as directed in previous CMS instructions;  3) Where applicable, continue to check additionally to determine if the incoming claim contains an entry or action code value of 1, along with Claim Adj ustment Indicator=A, as per previous CMS direction;  4) Confirm that the claim contains service lines where the amount allowed per line equals the amount paid per line;   5) Check for the presence of a B line LIAB IND in association with any of the denied servi ce lines on the claim;  6) Suppress the claim from the crossover process if the claim does not contain a B line LIAB IND for any of the denied service lines; and   7) Select the claim for crossover if even one of the denied lines contains a B LIAB IND.  Upon suppressing the Part B c laim from the crossover process, CWF shall annotate the claim on the Part B claim detail (PTBH) screen with a newly created AF (Fully reimbursable claim containing denied lines with no beneficiary liability) claims crossover disposition indicator. (See  80.5 of this chapter for more details regarding crossover disposition indicators.)   J.  Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied with No Additional Liability   The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) fully denied adjustment claims that carry no additional beneficiary liability when the COIF indicates that a COBA trading partner wishes to exclude such claims.
(Medicare Claims Processing Manual)
The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) fully denied adjustment claims that carry no additional beneficiary liability when the COIF indicates that a COBA trading partner wishes to exclude such claims.   Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment c laim (action code 3) where the entire claim is denied and the beneficiary has no additional liability.  As of January 4, 2010, that logic was changed to also include the reading of action code 8, in addition to action code 3, for HUIP and HUOP claims.  T he revised logic will thus be as follows:  1)  Verify that the claim was sent as action code 3;   2) Verify also if an HUIP or HUOP claim contains action code 8 rather than an action code 3; and   3)  Check for the presence of an N beneficiary liabil ity indicator in the header of the fully denied claim. (See the Beneficiary Liability Indicators on Part A CWF Claims Transactions section above for additional information.)   The CWF shall apply logic to the Part B and DM EPOS  adjustment claims (entry code 5) where the entire claim is denied and the beneficiary has no additional liability as follows:   1) Verify that the claim was sent as entry code 5; and   2) Check for the presence of an N liability indicator on the fully denie d claim.
(Medicare Claims Processing Manual)
1) Verify that the claim was sent as entry code 5; and   2) Check for the presence of an N liability indicator on the fully denie d claim.   The CWF maintainer shall create a new T crossover disposition indicator for adjustment claims that are 100 percent denied with no additional beneficiary liability.  The CWF maintainer shall ensure that excluded adjustment claims that were entir ely denied and contained no beneficiary liability shall be marked with a T crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add Denied Adjs-No Liab to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  K.  Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied with No Additional Liability  The CWF shall apply logic to exclude Part A and Part B (including DM EPOS ) fully denied adjustment claims that carry additional beneficiary liability when the COIF indicates that a COBA trading partner wishes to exclude such claims.  Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment claim (action code 3) where the entire claim is denied and  the beneficiary has additional liability. As of January 4, 2010, that logic shall be changed to also include the reading of action code 8, in addition to action code 3, for HUIP and H UOP claims.  The revised logic will thus be as follows:  1) Verify that the claim was sent as action code 3;   2) Verify also if an HUIP or HUOP claim contains action code 8 rather than an action code 3; and   3) Check for the presence of an L beneficiary liability indicator in the header of the fully denied claim. (See the Beneficiary Liability Indicators on Part A CWF Claims Transactions section above for additional information.)   The CWF shall apply logic to exclude Part B and DM EPOS  adjustment claims (e ntry code 5) where the entire claim is denied and the beneficiary has additional liability as follows:  1) Verify that the claim was sent as entry code 5; and   2) Check for the presence of an L liability indicator on the fully denied claim.
(Medicare Claims Processing Manual)
2) Check for the presence of an L liability indicator on the fully denied claim.  The CWF maintainer shall create a new U crossover disposition indicator for adjustment claims that are 100 percent denied with additional beneficiary liability.  The CWF maintainer shall ensure that excluded adjustment claims that were entirely denied and contained beneficiary liability shall be marked with a U crossover disposition indicator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add Denied Adjs-Liab to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.  L.  Excluding MSP Cost-Avoided Claims  The CWF shall develop logic to exclude MSP cost -avoided claims when the COIF indicates that a COBA trading partner wishes to exclude such claims.   The CWF shall apply the following logic to exclude Part A MSP cost -avoided claims:    Verify that the claim contains one of the following MSP non- pay codes:  E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26.  The CWF shall apply the following logic to exclude Part B and DMAC MSP cost -avoided claims:    Verify that the claim contains one of the following MSP non- pay codes:  E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18, 25, and 26.  The CWF maintainer shall create a new V crossover disposition indicator for the exclusion of MSP cost -avoided claims.  The CWF maintainer shall ensure that excluded MSP cost -avoided claims shall be marked with a V crossover disposition indic ator after they have been posted to the appropriate HIMR detailed history screen.  In addition, the CWF maintainer shall add MSP Cost -Avoids to the COBS on HIMR so that this exclusion will be appropriately displayed for customer service purposes.   M.  Ex cluding Sanctioned Provider Claims from the COBA Crossover Process
(Medicare Claims Processing Manual)
M.  Ex cluding Sanctioned Provider Claims from the COBA Crossover Process   Effective with April 2, 2007, the CWF maintainer create d space within the HUBC claim transaction for a newly developed S indicator, which designates sanctioned provider.   A/B MACs (B) that process claims from physicians (e.g., practitioners and specialists) and suppliers (independent laboratories and ambulance companies) shall set an S indicator in the header of a fully denied claim if the physician or supplier that is billing is suspended/sanctioned.  NOTE:  Such physicians or suppliers will have been identified by the Office of the Inspector General (OIG) and will have had their Medicare billing privileges suspended.  Before setting the S indicator in the header of a claim, the  A/B MAC (B) shall first split the claim it is contains service dates during which the provider is no longer sanctioned.  This will ensure that the A/B MAC (B) properly sets the S indicator for only those portions of the claim during which the provider i s sanctioned.   Upon receipt of an HUBC claim that contains an S indicator, the CWF shall exclude the claim from the COBA crossover process.  The CWF therefore shall not return a BOI reply trailer 29 to the A/B  MAC (B) for any HUBC claim that contains an S indicator.   N.  Overarching Adjustment Claim Exclusion Logic   Overarching adjustment claim logic is defined as the logic that CWF will employ, independent of a specific review of claim monetary changes, when a COBA trading partners COIF specifies th at it wishes to exclude all adjustment claims.   Modified  CWF Logic  Effective with April 1, 2008, the CWF maintainer shall change its systematic logic to accept a new version of the COIF that now features a new all adjustment claims exclusion option.  For the COBA eligibility file -based crossover process, where CWF utilizes both the BOI auxiliary record and the COIF when determining whether it should include or exclude a claim for crossover, CWF shall apply the overarching adjustment claim logic as follow s:   Verify that the incoming claim has an action code of 3 or entry code of 5 or , if the claim has an action or entry code of 1 (original claim), confirm whether it has an A claim header value, which designates adjustment claim for crossover purposes; and
(Medicare Claims Processing Manual)
 Verify that the COIF contains a marked exclusion for all adjustment claims.  If these conditions are met, CWF shall exclude the claim for crossover under the COBA eligibility file -based crossover process.  If both of these conditions are met, CWF shall exclude the claim for crossover under the COBA eligibility file -based crossover process.  IMPORTANT:   Independent of the foregoing requirements, CWF shall continue to only select an adjustment claim for COBA crossover purposes if :  1) it locates the matching original claim; and 2) it determines that the original claim was selected for crossover (see H.  Excluding Adjustment Claims When the Original Claim Was Also Excluded above for more information).  New Crossover Disposition Indicator   Upon excluding the claim, CWF shall mark the claim as it is stored on the appropriate HIMR claim detail history screen with a newly developed AC crossover disposition indicator, which designates that CWF excluded the claim because the COBA trading partner wished to exclude all adjustment claims.  (See 80.5 of this chapter for a description of this crossover disposition indicator.)  The CWF shall display the new indicator within the eligibility file -based crossover segment of the HIMR detailed claim history screen.  Exception Concerning COBA IDs in the Medigap Claim -based Range   CWF shall never apply the new overarching adjustment claim exclusion logic to incoming HUBC or HUDC claims whose field 34 (Crossover ID) h eader value falls within the range of 0000055000 to 0000059999, which represents the COBA identifier of a COBA Medigap claim -based crossover recipient, and for which there is not a corresponding BOI auxiliary record that likewise contains that insurer identifier.  (See 80.7 of this chapter for more information concerning the COBA Medigap claim -based crossover process.)   O.  Exclusion of Claims Containing Placeholder National Provider Identifier (NPI) Values   Effective October 6, 2008, the CWF maintainer cr eated space within the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a new 1 -byte NPI -Placeholder field (acceptable values=Y or space).
(Medicare Claims Processing Manual)
In addition, the CWF maintainer shall create space within page two (2) of the HIMR detail of the claim screen for 1) a new category COBA Bypass; and 2) a 2 -byte field for the indicator BN, which shall designate that CWF auto- excluded the claim because it contained a placeholder provider value (see 80.5 of this chapter for more details regarding the BN bypass indicator).   NOTE:   With the implementation of the October 2008 release, the CWF maintainer shall remove all current logic for placeholder provider values with the implementation of this new solution for identifying claims that contain placeholder provider values.  As MACs adjudicate non VA MRA claims that fall within any of the NPI placeholder requirements, their shared system shall take the following combined actions:   1) Input a Y value in the newly created NPI Placeholder f ield on the HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim transaction if a placeholder value exists on or is created anywhere within the SSM claim record ( NOTE :  Shared systems shall include spaces within the NPI Placeholder field when the claim does not contain a placeholder NPI value); and   2) Transmit the claim to CWF, as per normal requirements.   Upon receipt of claims where the NPI Placeholder field contains the value Y, CWF shall auto -exclude the claim from the national COBA crossover process.  In addition, CWF shall populate the value BN in association with the newly developed COBA Bypass field on page 2 of the HIMR Part B and DME MAC claim detail screens and on page 3 of the HIMR A/B MAC (A) claim detail screen.   P.  Excluding Physician Quality Reporting System  (PQR S) Only Codes Reported on 837 Professional Claims   Effective October 6, 2008, the CWF maintainer shall create space within the header of its HUBC claim transmission for a 1 -byte PQR S indicator (valid values=Q or space).
(Medicare Claims Processing Manual)
Effective October 6, 2008, the CWF maintainer shall create space within the header of its HUBC claim transmission for a 1 -byte PQR S indicator (valid values=Q or space).   In addition, CWF shall create a 2 -byte field on page 2 of the HIMR claim detail in association with the new category COBA Bypass for the value BQ, which shall designate that CWF auto -excluded the claim because it contained only PQR S codes (see 80.5 of this chapter for more details regarding the bypass indicator).   Prior to transmitting the claim to CWF for normal processing, MCS  shall input the value Q in the newly defined PQR S field in the header of the HUBC when all service lines on a claim contain PQRI (status M) codes.   Upon receipt of a claim that contains a Q in the newly defined PQR S field (which signifies that the claim contains only PQR S codes on all service detail lines, CWF shall auto-exclude the claim from the national COBA eligibility file -based and Medigap claim -based crossover processes.  Following exclusion of the claim, CWF shall populate the value BQ in association with the newly developed COBA Bypass field on page 2 of the HIMR Part B claim detail screen.
(Medicare Claims Processing Manual)
Q.  CWF Requirements for Health Care Pre -Payment Plans (HCPPs) that Receive Crossover Claims  Effective January 5, 2009, at CMSs direction, the BCRC  assign ed all HCPP COBA 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.  (Refer to chapter 28, 70.6 for MAC requirements in association with HCPP and HMO cost plan crossovers.)  R.  Inclusion or Exclusion of Part A Claims By Provider Identif ication Number (ID) as well as Provider State  Since July 2004, the CWF has read the incoming BCRC -created COIF to determine each national COBA trading partners specific claims selection as tied to each COBA ID.  To accommodate the inclusion or exclusion of Part A specific provider identifiers (IDs), CWF currently reads the numeric value reported on the COIF by COBA ID and then interrogates the Provider ID, CMS Certification Number (CCN) reported on the incoming HUIP, HUOP, HUHH, or HUHC claims transacti on.  For instances where a match is found, CWF either includes or excludes the claim from the national crossover process, in accordance with the I or E indicator that precedes the provider ID value reported beginning with field 225 of the COIF.  Also, since July 2004, CWF has read the 2- digit state code as referenced on the COIF as a basis for including or excluding Part A claims by provider state.  In performing this function, CWF locates the incoming Provider ID on the HUIP, HUOP, HUHH, or HUHC clai ms transaction and determines if the first 2 bytes match the 2 -byte state code on the BCRC -created COIF.   If a match is found, CWF either includes or excludes the claim based upon the I or E value reported in field 224 of the COIF.  Effective April 4,  2011, upon its receipt of either a 6-byte CMS Certification Number (CCN) or a 10 -digit NPI, as found starting in position 225 of the COIF, CWF shall check both the Provider ID and NPI fields of the incoming HUIP, HUOP, HUHH, or
(Medicare Claims Processing Manual)
or a 10 -digit NPI, as found starting in position 225 of the COIF, CWF shall check both the Provider ID and NPI fields of the incoming HUIP, HUOP, HUHH, or HUHC for potential matc hes.  If CWF finds a provider ID or NPI match, it shall either include or exclude the claim based upon the indicator (I or E) reported in field 224 of the COIF.