evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The CWF shall continue to either 1) include  the claim if the I indicator precedes the provider ID or NPI reported on the COIF or  2) exclude the claim and annotate Part A claims history with crossover indicator K when the reported provider ID or NPI on the COIF is identified for exclusion from the crossover process. (See 80.5 of this chapter f or more information concerning the K crossover disposition indicator.)  S.  Excluding Fully Denied Claims Adjudicated With An Other Adjustment (OA) Claim Adjustment Segment Group Code   Effective October 4, 2010, the CWF maintainer create d space within the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a 1 -byte Claim Adjustment Segment (CAS) Group Code Indicator field (valid values=G or space).  In addition, CWF developed a new 2 -byte BG COBA By -pass indicato r, which designates that CWF auto -excluded the claim because it was adjudicated with an OA CAS group code for all denied lines or services.  Prior to transmitting their adjudicated claims to CWF for normal processing, all shared systems shall input the value G in the newly defined 1-byte CAS Group Code Indicator field in the header of their HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claims when all services or claim detail service lines on the affected claims are denied with Group Code OA.  Upon receipt of a claim that contains a G in the newly defined CAS Group Code Indicator field, CWF shall auto- exclude the claim from the national COBA eligibility file-based and Medigap claim -based crossover processes.  ( NOTE:   CWF shall not be required to read the COIF to determine COBA trading partner preferences for claims containing either an L or N beneficiary liability indicator when the incoming claim contains a G in the newly defined CAS Group Code Indicator field.)  Following auto-exclusion of the cl aim, CWF shall take the following actions:  1)  Annotate the claim with a BG COBA bypass indicator; and   2)  Display the BG indicator as part of the COBA Bypass segment on page 3 of the appropriate HIMR claim detail screen.
(Medicare Claims Processing Manual)
1)  Annotate the claim with a BG COBA bypass indicator; and   2)  Display the BG indicator as part of the COBA Bypass segment on page 3 of the appropriate HIMR claim detail screen.   Effective with October 3, 2011, CWF create d a consistency edit that will activate when the shared systems send HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims to CWF that contain a value in the CAS Group Code Indicator field other than G or spaces.  Upon receipt of this consistency edit, the shared system shall take the following actions:  1) Modify the value reported in the CAS Group Code Indicator either to a G, if appropriate, or spaces; and   2) Retransmit the claim to CWF.   T.   New Requirements for Other Federal Payers   Effective wi th October 3, 2011, the CWF maintainer expand ed its logic for Other Insurance, which is COIF element 176, to include TRICARE for Life (COBA ID 60000 -69999) and CHAMPVA (COBA ID 80214), along with State Medicaid Agencies (70000-79999), as entities eligibl e for this exclusion.   Through these changes, if either TRICARE for Life or CHAMPVA wishes to invoke the Other Insurance exclusion, and if element 176 is marked on the COIF for these entities, CWF shall suppress claims from the national COBA crossover process if it determines that the beneficiary has active additional supplemental coverage.   As part of this revised Other Insurance logic for TRICARE and CHAMPVA, CWF shall interpret additional supplemental coverage as including entities whos e COBA identifiers fall in any of the following ranges:   00001- 29999 (Supplemental);  30000- 54999 (Medigap eligibility- based);  80000- 80213 (Other Insurer); and  80215- 88999 (Other Insurer).   The Other Insurance logic for State Medicaid Agencies includes al l of the following COBA ID ranges:
(Medicare Claims Processing Manual)
The Other Insurance logic for State Medicaid Agencies includes al l of the following COBA ID ranges:   00001- 29999 (Supplemental);  30000- 54999 (Medigap eligibility- based);  60000- 69999 (TRICARE);  80000- 80213 (Other Insurance)  80214 (CHAMPVA)  80215- 88999 (Other Insurer).   NOTE:   As of October 3, 2011, CWF shall now omit COBA ID range 89000- 89999 as part of its Other Insurance logic for State Medicaid Agencies.   CWF shall mark claims that it excludes due to Other Insurance with crossover disposition indicator M when storing t hem within the CWF claims history screens.  (See 80.5 of this chapter for additional information concerning this indicator.)   U.  CWF and Shared Systems Handling of Claims Where Principal Diagnosis Is E Code or Equivalent Code in Successive ICD Diagnosi s Versions   Effective April 1, 2013, CWF create d a new 1 -byte First Reported DX Code Indicator field within the header of incoming HUBC and HUDC claims transactions.  CWF shall only accept Y or spaces as valid values for the newly created First Reported DX Code Indicator within the header of incoming HUBC and HUDC claims and shall develop consistency edits to address invalid values submitted in the newly created field.  For applicable situations where claims having a principle (first -listed) E ICD -9 code or, when ICD -10 diagnosis coding is implemented,  equivalent V00--Y99 ICD -10 diagnosis code are either not rejected due to front -end editing or are returned as unproces sable, the Part B and DME MAC shared systems shall:    Input a Y indicator in the First Reported DX Code field (header) of the HUBC and HUDC  claims; and    Transmit the affected claims to CWF for normal processing.
(Medicare Claims Processing Manual)
 Input a Y indicator in the First Reported DX Code field (header) of the HUBC and HUDC  claims; and    Transmit the affected claims to CWF for normal processing.   The shared systems shall have the abilit y to react to CWF consistency edits received when invalid values are entered in the newly created DX Code Indicator field.  Upon receipt of claims that contain a Y in First Reported DX Code Indicator field, CWF shall by -pass the claims from crossing over .  CWF shall create a new BX COBA by-pass indicator that it will apply to claims where a Y is present within the DX Code Indicator field (See 80.5 of this chapter for more information regarding the new indicator).  Additionally, CWF shall display the new by- pass indicator on the appropriate page(s) of the HIMR claims detail screens.   80.5 - Claims Crossover Disposition and Coordination of Benefits Agreement Bypass Indicators  (Rev. 4474, Issued; 12- 06-19, Effective: 01 -04-20, Implementation: 01- 06-20)  1.  Claims Crossover Disposition Indicators   Effective with the October 2004 systems release, when a COBA trading partner is in production mode (Test/Production Indicator sent via the COIF submission=P), CWF shall annotate each processed claim on detailed  history in the HIMR with a claims crossover disposition indicator after it has applied the COBA trading partners claims selection criteria.  (See the table below for a listing of the indicators.)  In addition, when a COBA trading partner is in production mode, CWF shall annotate each processed claim with a 10-position COBA ID (5 -digit COBA ID preceded by 5 zeroes) to identify the entity to which the claim was crossed or not crossed, in accordance with the terms of the COBA.  Effective with October 2006, t he CWF maintainer updated its data elements/documentation to capture the revised descriptor for crossover disposition indicators E, as reflected below.  In addition, the CWF maintainer shall update its data elements/documentation to capture the newly add ed R, S, T, U, and V crossover disposition indicators, as reflected in the Claims Crossover Disposition Indicators table below.
(Medicare Claims Processing Manual)
Effective with July 2007, the CWF maintainer updated its data elements/ documentation to capture the newly added W, X, and Y crossover disposition indicators, as well as all other changes, reflected in the table directly below.   As reflected in the table below, the CWF maintainer created crossover disposition indicators Z and AA to be effective October 1, 2 007.  The CWF maintainer created a new AC crossover disposition indicator as part of its COBA claims selection processing effective April 1, 2008.  Effective January 5, 2009, the CWF maintainer created crossover disposition indicators AD and AE, as i ndicated in the table below.  The CWF shall utilize the AD indicator when an incoming claim does not meet any of the new adjustment, mass adjustment, or recovery audit contractor (RAC) -initiated adjustment inclusion criteria, as specified in 80.8 of thi s chapter.  The CWF shall utilize the AE indicator when the COBA trading partner specifies that it wishes to exclude RAC -initiated adjustments and CWF does not otherwise exclude the claim for some other reason identified higher within its crossover exclu sion logic hierarchy.   Effective with the July 2009 release, the CWF maintainer shall display all auto-exclude/COBA by- pass events, as detailed below, in association with an adjudicated claim within the COBA bypass field on page 3 of the HIMR intermediary claim detail screen and on page 2 of the HIMR Part B and DMEL detail screen.   The CWF shall, in addition, create and display a new BT crossover disposition exclusion indicator on pages 2 and 3 of the HIMR claim detail screens, as appropriate, effective w ith July 2009.
(Medicare Claims Processing Manual)
The CWF shall, in addition, create and display a new BT crossover disposition exclusion indicator on pages 2 and 3 of the HIMR claim detail screens, as appropriate, effective w ith July 2009.  Additionally, the CWF maintainer shall create additional fields within claim page 3 of the HIMR intermediary claim detail screen and page 2 of the Part B and DMEL claim detail screens to allow for the reporting of crossover disposition indi cators in association with test COBA crossover claims.  The CWF maintainer shall 1) create additional fields for displaying test crossover disposition indicators within both the eligibility file -based and claim -based crossover portions of the claim det ail screens on HIMR; and 2) display the test crossover disposition indicators so that they mirror all such indicators used for production claims in association with the following four (4) claim versions:   4010A1, 5010, National Council for Prescription Drug Programs (NCPDP)- 5.1, and NCPDP -D.0.    IMPORTANT:   If the BCRC transmits a COIF that contains a COBA ID within the range 79000 through 79999 (Medicaid quality project), CWF shall post an MQ disposition indicator in association with the claim inste ad of the traditional A indicator when it selects the claim for crossover.  ( NOTE:   MQ shall designate that Medicare is transferring the claim for Medicaid quality project purposes only.)  CWF shall annotate claims whose COBA ID is 79000 through 79999 with  MQ regardless of the claim version indicator in those instances where it selects the claims for crossover to the BCRC.  CWF shall also annotate the claims with MQ if the COBA ID is marked on the COIF as being in test (T) or production (P) mode.  If  CWF excludes from crossover a claim where the COBA ID equals 79000 through 79999, CWF shall continue to post the crossover disposition indicator that corresponds to the reason for the exclusion on the appropriate HIMR claim detail screen.
(Medicare Claims Processing Manual)
Effective January 4, 2010, CWF shall apply the newly developed crossover disposition indicator AF (see below) to incoming Part B original and adjustment fully paid claims, without deductible and co-insurance, when those claims contain denied service lines where the ben eficiary has no liability.  Effective April 6, 2020, CWF shall apply the newly developed crossover disposition indicator AG (see below) to incoming Part B claims that do not meet the Part B psychotherapy claims inclusion criteria.  In addition, CWF shall apply the newly developed crossover disposition indicator AH (see below) to incoming Part B claims that meet a COBA trading partners Part B psychotherapy claims exclusion criteria.    Claims Crossover Disposition Indicator  Definition/Description  A This claim was selected to be crossed over.  B This Type of Bill (TOB) excluded.  C Non-assigned claim excluded.  D Original Fully Paid Medicare claims without deductible and co -insurance remaining excluded.  E Original Medicare claims paid at greater than 100% of the submitted charges without deductible or co-insurance remaining excluded (Part A).
(Medicare Claims Processing Manual)
**Also covers the exclusion of Original Medicare claims paid at greater than 100% of the submitted charges excluded for Part B ambulatory surgical center (ASC) claims, even if deductible or co -insurance applies.  F 100% denied claims, with no additional beneficiary liability excluded.  G 100% denied claims, with additional beneficiary liability excluded.  H Adjustment claims, monetary, exclu ded (not representative of mass adjustments).  I Adjustment claims, non -monetary/statistical, excluded (not representative of mass adjustments).  J MSP claims excluded.  K This claim contains a provider identification number (ID) or provider state that is excluded by the COBA trading partner.  L Claims from this A/B MAC or DME MAC ID excluded.  M The beneficiary has other insurance (such as Medigap, supplemental, TRICARE, or other) that pays before Medicaid.  Claim excluded by Medicaid.  N NCPDP claims e xcluded.  O All Part A claims excluded.  P All Part B claims excluded.  Q All DME MAC claims excluded.  R Adjustment claim excluded because original claim was not crossed over.  S Adjustment fully paid claims with no deductible or co-Insurance remaining excluded.  T Adjustment Claims, 100% Denied, with no additional beneficiary liability excluded.  U Adjustment Claims, 100% Denied, with additional beneficiary liability excluded.  V MSP cost -avoided claims excluded.  W Mass Adjustment Claims Medicare Physician Fee Schedule (MPFS) excluded.  X Mass Adjustment Claims Other excluded.  Y Archived adjustment claim excluded.  Z Invalid Claim -based Medigap crossover ID included on the claim.  AA Beneficiary identified on Medigap insurer eligibility file; duplicate Medigap claim- based crossover voided  AB Not Used ; already utilized in another current CWF application or process.  AC All adjustment claims excluded.  AD Adjustment inclusion criteria not met.  AE Recovery audit A/B MAC or DME MAC (RAC) -initiated adjustment excluded.  BT Individual COBA ID did not have a matching COIF.  MQ Claim transferred for Medicaid quality project purposes only.  AF Fully reimbursable claim containing denied lines with no be neficiary liability excluded.  AG Part B psychotherapy claims inclusion criteria not met. AH Part B psychotherapy claims excluded.  AV Void/cancel claim suppressed because the original claim was excluded
(Medicare Claims Processing Manual)
2.  COBA By pass Indicators   Effective with the October 2008 release, the CWF maintainer shall display COBA bypass indicators in association with claims posted on HIMR.  These indicators will appear on page 2 of the PTBH and DMEH screens and on page 3 of the INPH, OUTH, HHAH, or HOSH screens.  The COBA Bypass Indicators appear in the table directly below.  Effective with the July 2009 release, the CWF maintainer shall additionally display bypass indicators BA, BB, BC, BD, BE, BF, BP, and BR on the appropriate detailed screens (PTBH or DMEH; INPH, OUTH, HHAH, or HOSH) on HIMR.   Effective with the October 2010 release, the CWF maintainer shall display the new BG COBA bypass indicator on the appropriate claim detail screens (PTBH, DMEH, INPH, OUTH, HHAH, or HOSH) on HIMR.   Effective April 1, 2013, the CWF maintainer shall display the new BX COBA bypass indicator on the appropriate claim detail screens (PTBH, DMEH, INPH , OUTH, HHAH, or HOSH) on HIMR.  Effective July 1, 2019, the CWF maintainer shall display the new BY COBA bypass indicator on the appr opriate claim detail screens (PTBH, DMEH, INPH, OUTH, HHAH, or HOSH) on HIMR.
(Medicare Claims Processing Manual)
Claims Crossover Bypass Indicator  Definition/Description  BA Claim represents an Add History only (action code 7 on HUOP claims; entry code 9 on HUBC and HUDC claims). Therefo re, the claim is bypassed and not crossed over.  BB Claim falls into one of two situations: 1) there is no eligibility record (exception:  if HUBC or HUDC claim has a Medigap claim -based COBA ID); or  2) the only available eligibility record contains a Y delete indicator. Therefore, the claim is bypassed and not crossed over.  BC Claim represents an abbreviated encounter record (TOB=11z; condition code=04 or 69); therefore, the claim is bypassed and not crossed over.  BD Claim contains a Part B/DME MAC CWF claim disposition code other than 01, 03, or 05; therefore, the claim is bypassed and not crossed over.  BE Submission of Notice of Elections [NOEs] (HospiceTOB= 8xA through 8xE on HUHC; CEPP TOB=11A through 11D on HUIP; Religious Non- Medical CareTOB=41A, 41B, and 41D on HUIP; Medicare Coordinated Care TOB=89A and 89B on HUOP).  Therefore, the submission is bypassed and not crossed over. BF Claim represents an excluded demonstration (DEMO) project; therefore, the claim is bypassed and not crossed over. Claims Crossover Bypass Indicator  Definition/Description  BG CWF auto -excluded the claim because it was adjudicated with an OA Claim Adjustment Segment (CAS) Group code for all  denied lines or services.  BN CWF auto -excluded the claim because it contained a placeholder provider value. BP Sanctioned provider claim during service dates indicated; therefore, the claim is bypassed and not crossed over. BQ CWF auto -excluded the claim because it contained only PQRS codes. BR Submission for Request for Anticipated Payment [RAP] claims (TOB=322 and 332); therefore, the submission is bypassed and not crossed over. BX Non-compliant ICD DX code on claim; therefore, the claim is by -passed and not crossed over.   BY  A BOI record exists, but there are no active BOI entries that correspond to the claim's service dates. Therefore, the claim is bypassed and not crossed over.
(Medicare Claims Processing Manual)
BY  A BOI record exists, but there are no active BOI entries that correspond to the claim's service dates. Therefore, the claim is bypassed and not crossed over.   80.6 - Special Mass Adjustment and Other Adjustment Crossover Requirements                                                                                                    (Rev. 4009, Issued: 03- 23-18, Effective: 04-23-18, Implementation: 04-23-18) 1.  Developing a Capability to Exclude Mass Adjustment Claims Tied to the Medicare Physician Fee Schedule Updates and Mass Adjustment Claims -Other  Effective with July 2, 2007, the CWF maintainer create d a new header field for a one (1) -byte mass adjustment indicator within its HUBC, HUDC, HUOP, HUHH, and HUHC claims transaction s.  The valid values for the newly created field shall be M mass adjustment claim- Medicare Physician Fee Schedule (MPFS) and O mass adjustment claim -other.  Further, effective with that date, the BCRC shall send the CWF host sites a modified COIF that contains two new claims exclusion categories:  mass adjustments -MPFS and mass adjustments-other.  Upon receipt of a claim that contains an M indicator (new field) in the header of an HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim, CWF shall read the COIF to  determine whether the COBA trading partner wishes to exclude the claim.  If CWF determines that the trading partner wishes to exclude the mass adjustment- MPFS claim, it shall exclude the claim from the COBA crossover process.   Upon receipt of a claim that  contains an O indicator in the header of an HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim, which designates mass adjustment claim- other, the CWF shall read the COIF to determine whether the COBA trading partner wishes to exclude the claim.  If CWF deter mines that the trading partner wishes to exclude mass adjustment claims -other, it shall exclude the claim from the COBA crossover process.   Creation of New Crossover Disposition Indicators
(Medicare Claims Processing Manual)
Creation of New Crossover Disposition Indicators   In relation to its receipt of a claim that has either an M or an  O header value, the CWF shall create two new crossover disposition indicators W (mass adjustment claim -MPFS) and X (mass adjustments claim- other excluded) on the HIMR detailed history screens in association with excluded processed claims for production COBA trading partner.  The CWF shall display each of the new crossover disposition indicators appropriately in association with the processed mass adjustment claim- MPFS on the HIMR detailed history screen.  (See 80.5 of this chapter for further i nformation.)  In addition, the CWF maintainer shall develop and display two (2) new exclusion fields within the COBA Inquiry Screen (COBS) for mass adj.- M (mass adjustments -MPFS) and mass adj. -O (mass adjustments -other).  2.  Developing a Capability to Treat Entry Code 5 and Action Code 3 Claims As  Recycled Original Claims For Crossover Purposes   Effective with July 2007, the CWF maintainer shall create a new header field within its HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims transactions for a 1 -byte -adjustment indicator (valid values=N --non adjustment claim for crossover purposes;  A-- adjustment claim for crossover purposes; or space s).  In instances when CWF returns an error code 5600 to a n A/B MAC or DME MAC,  thereby c ausing it to reset the claims entry code to 5 to action code to 3, the A/B MAC or DME MAC  shall set a newly developed N non -adjustment claim indicator (treat as an original claim for crossover purposes) in the header of the HUBC, HUDC, HUIP, HUOP,  HUHH, HUIP, HUOP, HUHH, and HUHC claim in the newly defined field before retransmitting the claim to CWF.  The A /B MAC or DME MACs  system shall then resend the claim to CWF.
(Medicare Claims Processing Manual)
Upon receipt of a claim that contains entry code 5 or action code 3 with a non-adjustment claim header value of N, the CWF shall treat the claim as if it were an original claim (i.e., as entry code 1 or action code 1) for crossover inclusion or exclusion determinations.  If CWF subsequently determines that the claim meets  all other inclusion criteria, it shall mark the claim with an A (claim was selected to be crossed over) crossover disposition indicator.  Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF Beneficiary Other Insurance (BOI) Reply Tra iler 29 for Such Claims   Upon receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) for the recycled claim, 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) segment with a value of 1 (original).  In addition, the shared systems shall ensure that, as part of their 837 flat file creation process, they do not create a corresponding 2330 loop REF*T4*Y segment, which typically signi fies adjustment.   3. Developing a Capability to Treat Claims with Non -Adjustment Entry or Action Codes as Adjustment Claims For Crossover Purposes   In instances where A/B MACs and DME MACs  must send adjustment claims to CWF as entry code 1 or action code 1 (situations where the accrete claim cannot be processed at CWF), they shall set an A indicator in a newly defined field within the header of the HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim.   Upon receipt of a claim that contains entry code 1 or action code 1 with a claim adjustment indicator value of A, the CWF shall take the following actions:    Verify that, as per the COIF, the COBA trading partner wishes to exclude either adjustments, monetary or adjustments, non- monetary, or both ; and    Suppress the claim from crossover if the COBA trading partner wishes to exclude either adjustments, monetary or adjustments, non- monetary, or both.