1 CMS RIF REPORT FOR RECORD: DMERC_CLM_REC, STATUS: PROD, VERSION: 21006 PRINTED: 01/29/2021, USER: F43D, DATA SOURCE: CA REPOSITORY ON DB2T NAME LENGTH BEG END CONTENTS ------------------------------------------------------------------------------------------------------------------------------- *** DMERC Claim Record (NCH) VAR 1 18927 REC STANDARD ALIAS : DMERC_CLM_REC SYSTEM ALIAS : UTLDMERL LIMITATIONS : REFER TO : CHOICES_DEMO_LIM PMT_AMT_EXCEDG_CHRG_AMT_LIM 1. DMERC Claim Fixed Group 1058 1 1058 GRP 2. Claim Record Identification Group 8 1 8 GRP Effective with Version 'I' the record length, version code, record identification, code and NCH derived claim type code were moved to this group for internal NCH processing. STANDARD ALIAS : CLM_REC_IDENT_GRP 3. Record Length Count 3 1 3 PACK Effective with Version H, the count (in bytes) of the length of the claim record. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : REC_LNGTH_CNT SAS ALIAS : REC_LEN STANDARD ALIAS : REC_LNGTH_CNT LENGTH : 5 SIGNED : Y SOURCE : NCH 4. NCH Near-Line Record Version Code 1 4 4 CHAR The code indicating the record version of the Nearline file where the institutional, carrier or DMERC claims data are stored. DB2 ALIAS : NCH_REC_VRSN_CD SAS ALIAS : REC_LVL STANDARD ALIAS : NCH_NEAR_LINE_REC_VRSN_CD TITLE ALIAS : NCH_VERSION LENGTH : 1 COMMENTS : Prior to Version H this field was named: CLM_NEAR_LINE_REC_VRSN_CD. SOURCE : NCH CODE TABLE : NCH_NEAR_LINE_REC_VRSN_TB 5. NCH Near Line Record Identification Code 1 5 5 CHAR A code defining the type of claim record being processed. COMMON ALIAS : RIC DB2 ALIAS : NEAR_LINE_RIC_CD SAS ALIAS : RIC_CD STANDARD ALIAS : NCH_NEAR_LINE_RIC_CD TITLE ALIAS : RIC LENGTH : 1 COMMENTS : Prior to Version H this field was named: RIC_CD. SOURCE : NCH CODE TABLE : NCH_NEAR_LINE_RIC_TB 6. NCH MQA RIC Code 1 6 6 CHAR Effective with Version H, the code used (for internal editing purposes) to identify the record being processed through CMS' CWFMQA system. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : NCH_MQA_RIC_CD SAS ALIAS : MQA_RIC STANDARD ALIAS : NCH_MQA_RIC_CD TITLE ALIAS : MQA_RIC LENGTH : 1 SOURCE : NCH QA PROCESS CODE TABLE : NCH_MQA_RIC_TB 7. NCH Claim Type Code 2 7 8 CHAR The code used to identify the type of claim record being processed in NCH. NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991). NOTE2: During the Version I conversion this field was expanded to include inpatient 'full' encounter claims (for service dates after 6/30/97). NOTE3: Effective with Version 'J', 3 new code values have been added to include a type code for the Medicare Advantage claims (IME/GME, no-pay and paid as FFS). During the Version 'J' conversion, these type codes were populated throughout history. With Version 'J', these claims are also being stored in NMUD. Prior to Version 'J' they were only in the NCH. No history was converted in NMUD. DB2 ALIAS : NCH_CLM_TYPE_CD SAS ALIAS : CLM_TYPE STANDARD ALIAS : NCH_CLM_TYPE_CD TITLE ALIAS : CLAIM_TYPE LENGTH : 2 DERIVATIONS : FFS CLAIM TYPE CODES DERIVED FROM: NCH CLM_NEAR_LINE_RIC_CD NCH PMT_EDIT_RIC_CD NCH CLM_TRANS_CD NCH PRVDR_NUM INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM: (Pre-HDC processing -- AVAILABLE IN NCH) CLM_MCO_PD_SW CLM_RLT_COND_CD MCO_CNTRCT_NUM MCO_OPTN_CD MCO_PRD_EFCTV_DT MCO_PRD_TRMNTN_DT DERIVATION RULES: SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U' 2. PMT_EDIT_RIC_CD EQUAL 'F' 3. CLM_TRANS_CD EQUAL '5' SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '0' OR '4' 4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z' SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'W' 2. PMT_EDIT_RIC_CD EQUAL 'D' 3. CLM_TRANS_CD EQUAL '6' SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'I' 3. CLM_TRANS_CD EQUAL 'H' SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '1' 2. CLM_RLT_COND_CD = '04' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'V' 2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E' 3. CLM_TRANS_CD EQUAL '1' '2' OR '3' 4. FI_NUM = 80881 SET CLM_TYPE_CD TO 62 (Medicare Advantage IME/GME CLAIMS - 10/1/05 - FORWARD) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_MCO_PD_SW = '0' 2. CLM_RLT_COND_CD = '04' & '69' 3. MCO_CNTRCT_NUM MCO_OPTN_CD = 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET CLM_TYPE_CD TO 63 (HMO NO-PAY CLAIMS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED ON OR AFTER 10/6/08 1. CLM_THRU_DT ON OR AFTER 10/1/06 2. CLM_MCO_PD_SW = '1' 3. CLM_RLT_COND_CD = '04' 4. MCO_CNTRCT_NUM MCO_OPTN_CD = 'A', 'B' OR 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS 5. ZERO REIMBURSEMENT (CLM_PMT_AMT) SET CLM_TYPE_CD TO 63 (HMO NO-PAY CLAIMS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED PRIOR to 10/6/08 1. MCO_CNTRCT_NUM MCO_OPTN_CD = 'A', 'B' OR 'C' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS 2. ZERO REIMBURSEMENT (CLM_PMT_AMT) SET CLM_TYPE_CD TO 64 (HMO CLAIMS PAID AS FFS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED PRIOR to 10/6/08 1. MCO_CNTRCT_NUM MCO_OPTN_CD = '1', '2' OR '4' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET CLM_TYPE_CD TO 64 (HMO CLAIMS PAID AS FFS) WHERE THE FOLLOWING CONDITIONS ARE MET: CLAIMS PROCESSED on or after 10/6/08 1. CLM_RLT_COND_CD = '04' 2. MCO_CNTRCT_NUM MCO_OPTN_CD = '1', '2' OR '4' CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'O' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD not on DMEPOS table SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM) WHERE THE FOLLOWING CONDITIONS ARE MET: 1. CLM_NEAR_LINE_RIC_CD EQUAL 'M' 2. HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table). SOURCE : NCH LIMITATIONS : REFER TO : NCH_CLM_TYPE_CD_LIM CODE TABLE : NCH_CLM_TYPE_TB 8. Carrier/DMERC Claim Link Group 125 9 133 GRP Effective with Version 'I', this group was added to the carrier and DMERC records to keep fields common across all record types in the same position. Due to OP PPS, several fields on the Institutional record had to be moved to a link group so those same fields had to be moved on the carrier records eventhough OP PPS only affects institutional claims. STANDARD ALIAS : CARR_DMERC_CLM_LINK_GRP 9. Claim Locator Number Group 11 9 19 GRP This number uniquely identifies the beneficiary in the NCH Nearline. COMMON ALIAS : HIC STANDARD ALIAS : CLM_LCTR_NUM_GRP TITLE ALIAS : HICAN 10. Beneficiary Claim Account Number 9 9 17 CHAR The number identifying the primary beneficiary under the SSA or RRB programs submitted. COMMON ALIAS : CAN DB2 ALIAS : BENE_CLM_ACNT_NUM SAS ALIAS : CAN STANDARD ALIAS : BENE_CLM_ACNT_NUM TITLE ALIAS : CAN LENGTH : 9 SOURCE : SSA,RRB LIMITATIONS : REFER TO : CLM_ACNT_NUM_LIM 11. NCH Category Equatable Beneficiary Identification Code 2 18 19 CHAR The code categorizing groups of BICs representing similar relationships between the beneficiary and the primary wage earner. The equatable BIC module electronically matches two records that contain different BICs where it is apparent that both are records for the same beneficiary. It validates the BIC and returns a base BIC under which to house the record in the National Claims History (NCH) databases. (All records for a beneficiary are stored under a single BIC.) COMMON ALIAS : NCH_BASE_CATEGORY_BIC DB2 ALIAS : CTGRY_EQTBL_BIC SAS ALIAS : EQ_BIC STANDARD ALIAS : NCH_CTGRY_EQTBL_BIC_CD TITLE ALIAS : EQUATED_BIC LENGTH : 2 COMMENTS : Prior to Version H this field was named: CTGRY_EQTBL_BENE_IDENT_CD. SOURCE : BIC EQUATE MODULE CODE TABLE : CTGRY_EQTBL_BENE_IDENT_TB 12. Beneficiary Identification Code 2 20 21 CHAR The code identifying the type of relationship between an individual and a primary Social Security Administration (SSA) beneficiary or a primary Railroad Board (RRB) beneficiary. COMMON ALIAS : BIC DB2 ALIAS : BENE_IDENT_CD SAS ALIAS : BIC STANDARD ALIAS : BENE_IDENT_CD TITLE ALIAS : BIC LENGTH : 2 SOURCE : SSA/RRB EDIT RULES : EDB REQUIRED FIELD CODE TABLE : BENE_IDENT_TB 13. NCH State Segment Code 1 22 22 CHAR The code identifying the segment of the NCH Nearline file containing the beneficiary's record for a specific service year. Effective 12/96, segmentation is by CLM_LCTR_NUM, then final action sequence within residence state. (Prior to 12/96, segmentation was by ranges of county codes within the residence state.) DB2 ALIAS : NCH_STATE_SGMT_CD SAS ALIAS : ST_SGMT STANDARD ALIAS : NCH_STATE_SGMT_CD TITLE ALIAS : NEAR_LINE_SEGMENT LENGTH : 1 COMMENTS : Prior to Version H this field was named: BENE_STATE_SGMT_NEAR_LINE_CD. SOURCE : NCH CODE TABLE : NCH_STATE_SGMT_TB 14. Beneficiary Residence SSA Standard State Code 2 23 24 CHAR The SSA standard state code of a beneficiary's residence. DB2 ALIAS : BENE_SSA_STATE_CD SAS ALIAS : STATE_CD STANDARD ALIAS : BENE_RSDNC_SSA_STD_STATE_CD TITLE ALIAS : BENE_STATE_CD LENGTH : 2 COMMENTS : 1. Used in conjunction with a county code, as selection criteria for the determination of payment rates for HMO reimbursement. 2. Concerning individuals directly billable for Part B and/or Part A premiums, this element is used to determine if the beneficiary will receive a bill in English or Spanish. 3. Also used for special studies. SOURCE : SSA/EDB EDIT RULES : OPTIONAL: MAY BE BLANK CODE TABLE : GEO_SSA_STATE_TB 15. Claim From Date 8 25 32 NUM The first day on the billing statement covering services rendered to the bene- ficiary (a.k.a. 'Statement Covers From Date'). NOTE: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match. DB2 ALIAS : CLM_FROM_DT SAS ALIAS : FROM_DT STANDARD ALIAS : CLM_FROM_DT TITLE ALIAS : FROM_DATE LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 16. Claim Through Date 8 33 40 NUM The last day on the billing statement covering services rendered to the beneficiary (a.k.a 'Statement Covers Thru Date'). NOTE: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match. DB2 ALIAS : CLM_THRU_DT SAS ALIAS : THRU_DT STANDARD ALIAS : CLM_THRU_DT TITLE ALIAS : THRU_DATE LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 17. NCH Weekly Claim Processing Date 8 41 48 NUM The date the weekly NCH database load process cycle begins, during which the claim records are loaded into the Nearline file. This date will always be a Friday, although the claims will actually be appended to the database subsequent to the date. DB2 ALIAS : NCH_WKLY_PROC_DT SAS ALIAS : WKLY_DT STANDARD ALIAS : NCH_WKLY_PROC_DT TITLE ALIAS : NCH_PROCESS_DT LENGTH : 8 SIGNED : N COMMENTS : Prior to Version H this field was named: HCFA_CLM_PROC_DT. SOURCE : NCH EDIT RULES : YYYYMMDD 18. CWF Claim Accretion Date 8 49 56 NUM The date the claim record is accreted (posted/ processed) to the beneficiary master record at the CWF host site and authorization for payment is returned to the fiscal interme- diary or carrier. DB2 ALIAS : CWF_CLM_ACRTN_DT SAS ALIAS : ACRTN_DT STANDARD ALIAS : CWF_CLM_ACRTN_DT TITLE ALIAS : ACCRETION_DT LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 19. CWF Claim Accretion Number 2 57 58 PACK The sequence number assigned to the claim record when accreted (posted/processed) to the beneficiary master record at the CWF host site on a given date. This element indicates the position of the claim within that day's processing at the CWF host. **(Exception: If the claim record is missing the accretion date CMS' CWFMQA system places a zero in the accretion number. DB2 ALIAS : CWF_CLM_ACRTN_NUM SAS ALIAS : ACRTN_NM STANDARD ALIAS : CWF_CLM_ACRTN_NUM TITLE ALIAS : ACCRETION_NUMBER LENGTH : 3 SIGNED : Y SOURCE : CWF 20. Carrier Claim Control Number 15 59 73 CHAR Unique control number assigned by a carrier to a non-institutional claim. COMMON ALIAS : CCN DB2 ALIAS : CARR_CLM_CNTL_NUM SAS ALIAS : CARRCNTL STANDARD ALIAS : CARR_CLM_CNTL_NUM TITLE ALIAS : CCN LENGTH : 15 COMMENTS : For the physician/supplier or DMERC claim, this field allows CMS to associate each line item with its respective claim. SOURCE : CWF EDIT RULES : LEFT JUSTIFY 21. FILLER 38 74 111 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 38 22. NCH Daily Process Date 8 112 119 NUM Effective with Version H, the date the claim record was processed by CMS' CWFMQA system (used for internal editing purposes). Effective with Version I, this date is used in conjunction with the NCH Segment Link Number to keep claims with multiple records/ segments together. NOTE1: With Version 'H' this field was populated with data beginning with NCH weekly process date 10/3/97. Under Version 'I' claims prior to 10/3/97, that were blank under Version 'H', were populated with a date. DB2 ALIAS : NCH_DAILY_PROC_DT SAS ALIAS : DAILY_DT STANDARD ALIAS : NCH_DAILY_PROC_DT TITLE ALIAS : DAILY_PROCESS_DT LENGTH : 8 SIGNED : N SOURCE : NCH LIMITATIONS : REFER TO : NCH_DAILY_PROC_DT_LIM EDIT RULES : YYYYMMDD 23. NCH Segment Link Number 5 120 124 PACK Effective with Version 'I', the system gen- erated number used in conjunction with the NCH daily process date to keep records/segments belonging to a specific claim together. This field was added to ensure that records/ segments that come in on the same batch with the same identifying information in the link group are not mixed with each other. NOTE: During the Version I conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : NCH_SGMT_LINK_NUM SAS ALIAS : LINK_NUM STANDARD ALIAS : NCH_SGMT_LINK_NUM TITLE ALIAS : LINK_NUM LENGTH : 9 SIGNED : Y SOURCE : NCH 24. Claim Total Segment Count 2 125 126 NUM Effective with Version I, the count used to identify the total number of segments associated with a given claim. Each claim could have up to 10 segments. NOTE: During the Version I conversion, this field was populated with data throughout history (back to service year 1991). For institutional claims, the count for claims prior to 7/00 will be 1 or 2 (1 if 45 or less revenue center lines on a claim and 2 if more than 45 revenue center lines on a claim). For noninstitutional claims, the count will always be 1. DB2 ALIAS : TOT_SGMT_CNT SAS ALIAS : SGMT_CNT STANDARD ALIAS : CLM_TOT_SGMT_CNT TITLE ALIAS : SEGMENT_COUNT LENGTH : 2 SIGNED : N SOURCE : CWF 25. Claim Segment Number 2 127 128 NUM Effective with Version I, the number used to identify an actual record/segment (1 - 10) associated with a given claim. NOTE: During the Version I conversion this field was populated with data throughout history (back to service year 1991). For institutional claims prior to 7/00, this number will be either 1 or 2. For noninstitutional claims, the number will always be 1. DB2 ALIAS : CLM_SGMT_NUM SAS ALIAS : SGMT_NUM STANDARD ALIAS : CLM_SGMT_NUM TITLE ALIAS : SEGMENT_NUMBER LENGTH : 2 SIGNED : N SOURCE : CWF 26. Claim Total Line Count 3 129 131 NUM Effective with Version I, the count used to identify the total number of revenue center lines associated with the claim. NOTE: During the Version I conversion this field was populated with data throughout history (back to service year 1991). Prior to Version 'I', the maximum line count will be no more than 58. Effective with Version 'I', the maximum line count could be 450. DB2 ALIAS : TOT_LINE_CNT SAS ALIAS : LINECNT STANDARD ALIAS : CLM_TOT_LINE_CNT TITLE ALIAS : TOTAL_LINE_COUNT LENGTH : 3 SIGNED : N SOURCE : CWF 27. Claim Segment Line Count 2 132 133 NUM Effective with Version I, the count used to identify the number of lines on a record/ segment. NOTE: During the Version I conversion this field was populated with data throughout history (back to service year 1991). The maximum line count per record/segment on the revenue center trailer is 45. The maximum number of lines on carrier and DMERC claims are 13. DB2 ALIAS : SGMT_LINE_CNT SAS ALIAS : SGMTLINE STANDARD ALIAS : CLM_SGMT_LINE_CNT TITLE ALIAS : SEGMENT_LINE_COUNT LENGTH : 2 SIGNED : N SOURCE : CWF 28. Carrier/DMERC Claim Common 2 Group 911 134 1044 GRP 29. FILLER 5 134 138 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 5 30. Carrier Claim Entry Code 1 139 139 CHAR Carrier-generated code describing whether the Part B claim is an original debit, full credit, or replacement debit. DB2 ALIAS : CARR_CLM_ENTRY_CD SAS ALIAS : ENTRY_CD STANDARD ALIAS : CARR_CLM_ENTRY_CD TITLE ALIAS : ENTRY_CD LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_CLM_ENTRY_CD. SOURCE : CWF CODE TABLE : CARR_CLM_ENTRY_TB 31. FILLER 1 140 140 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 1 32. Claim Disposition Code 2 141 142 CHAR Code indicating the disposition or outcome of the processing of the claim record. DB2 ALIAS : CLM_DISP_CD SAS ALIAS : DISP_CD STANDARD ALIAS : CLM_DISP_CD TITLE ALIAS : DISPOSITION_CD LENGTH : 2 SOURCE : CWF CODE TABLE : CLM_DISP_TB 33. NCH Edit Disposition Code 2 143 144 CHAR Effective with Version H, a code used (for internal editing purposes) to indicate the disposition of the claim after editing in the CWFMQA process. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : NCH_EDIT_DISP_CD SAS ALIAS : EDITDISP STANDARD ALIAS : NCH_EDIT_DISP_CD TITLE ALIAS : NCH_EDIT_DISP LENGTH : 2 SOURCE : NCH QA Process CODE TABLE : NCH_EDIT_DISP_TB 34. NCH Claim BIC Modify H Code 1 145 145 CHAR Effective with Version H, the code used (for internal editing purposes) to identify a claim record that was submitted with an incorrect HA, HB, or HC BIC. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : NCH_BIC_MDFY_CD SAS ALIAS : BIC_MDFY STANDARD ALIAS : NCH_CLM_BIC_MDFY_CD TITLE ALIAS : BIC_MODIFY_CD LENGTH : 1 SOURCE : NCH QA Process CODE TABLE : NCH_CLM_BIC_MDFY_TB 35. Beneficiary Residence SSA Standard County Code 3 146 148 CHAR The SSA standard county code of a beneficiary's residence. DB2 ALIAS : BENE_SSA_CNTY_CD SAS ALIAS : CNTY_CD STANDARD ALIAS : BENE_RSDNC_SSA_STD_CNTY_CD TITLE ALIAS : BENE_COUNTY_CD LENGTH : 3 SOURCE : SSA/EDB EDIT RULES : OPTIONAL: MAY BE BLANK 36. Carrier Claim Receipt Date 8 149 156 NUM The date the carrier receives the non- institutional claim. DB2 ALIAS : CLM_RCPT_DT SAS ALIAS : RCPT_DT STANDARD ALIAS : CARR_CLM_RCPT_DT LENGTH : 8 SIGNED : N COMMENTS : Prior to Version 'H' this field was named: FICARR_CLM_RCPT_DT. SOURCE : CWF EDIT RULES : YYYYMMDD 37. Carrier Claim Scheduled Payment Date 8 157 164 NUM The scheduled date of payment to the physician or supplier, as appearing on the original non- institutional claim sent to the CWF host. **Note: This date is considered to be the date paid since no additional information as to the actual payment date is available. DB2 ALIAS : CARR_SCHLD_PMT_DT SAS ALIAS : SCHLD_DT STANDARD ALIAS : CARR_CLM_SCHLD_PMT_DT TITLE ALIAS : SCHLD_PMT_DT LENGTH : 8 SIGNED : N COMMENTS : Prior to Version H this field was named: FICARR_CLM_PMT_DT. SOURCE : CWF EDIT RULES : YYYYMMDD 38. CWF Forwarded Date 8 165 172 NUM Effective with Version H, the date CWF forwarded the claim record to CMS (used for internal editing purposes). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : CWF_FRWRD_DT SAS ALIAS : FRWRD_DT STANDARD ALIAS : CWF_FRWRD_DT TITLE ALIAS : FORWARD_DT LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 39. Carrier Number 5 173 177 CHAR The identification number assigned by CMS to a carrier authorized to process claims from a physician or supplier. Effective July 2006, the Medicare Administrative Contractors (MACs) began replacing the existing carriers and started processing physician or supplier claim records for states assigned to its jurisdiction. NOTE: The 5-position MAC number will be housed in the existing CARR_NUM field. During the transi- tion from a carrier to a MAC the CARR_NUM field could contain either a Carrier number or a MAC number. See the CARR_NUM table of codes to identify the new MAC numbers and their effective dates. DB2 ALIAS : CARR_NUM SAS ALIAS : CARR_NUM STANDARD ALIAS : CARR_NUM TITLE ALIAS : CARRIER LENGTH : 5 COMMENTS : Prior to Version H this field was named: FICARR_IDENT_NUM. SOURCE : CWF CODE TABLE : CARR_NUM_TB 40. FILLER 8 178 185 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 8 41. CWF Transmission Batch Number 4 186 189 CHAR Effective with Version H, the number assigned to each batch of claims transactions sent from CWF(used for internal editing purposes). NOTE: Beginning 11/98, this field will be populated with data. Claims processed prior to 11/98 will contain spaces in this field. DB2 ALIAS : TRNSMSN_BATCH_NUM SAS ALIAS : FIBATCH STANDARD ALIAS : CWF_TRNSMSN_BATCH_NUM TITLE ALIAS : BATCH_NUM LENGTH : 4 SOURCE : CWF 42. Beneficiary Mailing Contact ZIP Code 9 190 198 CHAR The ZIP code of the mailing address where the beneficiary may be contacted. DB2 ALIAS : BENE_MLG_ZIP_CD SAS ALIAS : BENE_ZIP STANDARD ALIAS : BENE_MLG_CNTCT_ZIP_CD TITLE ALIAS : BENE_ZIP LENGTH : 9 SOURCE : EDB 43. Beneficiary Sex Identification Code 1 199 199 CHAR The sex of a beneficiary. COMMON ALIAS : SEX_CD DB2 ALIAS : BENE_SEX_IDENT_CD SAS ALIAS : SEX STANDARD ALIAS : BENE_SEX_IDENT_CD TITLE ALIAS : SEX_CD LENGTH : 1 SOURCE : SSA,RRB,EDB EDIT RULES : REQUIRED FIELD CODE TABLE : BENE_SEX_IDENT_TB 44. Beneficiary Race Code 1 200 200 CHAR The race of a beneficiary. DB2 ALIAS : BENE_RACE_CD SAS ALIAS : RACE STANDARD ALIAS : BENE_RACE_CD TITLE ALIAS : RACE_CD LENGTH : 1 SOURCE : SSA CODE TABLE : BENE_RACE_TB 45. Beneficiary Birth Date 8 201 208 NUM The beneficiary's date of birth. COMMON ALIAS : DOB DB2 ALIAS : BENE_BIRTH_DT SAS ALIAS : BENE_DOB STANDARD ALIAS : BENE_BIRTH_DT TITLE ALIAS : BENE_BIRTH_DATE LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 46. CWF Beneficiary Medicare Status Code 2 209 210 CHAR The CWF-derived reason for a beneficiary's entitlement to Medicare benefits, as of the reference date (CLM_THRU_DT). COMMON ALIAS : MSC DB2 ALIAS : BENE_MDCR_STUS_CD SAS ALIAS : MS_CD STANDARD ALIAS : CWF_BENE_MDCR_STUS_CD TITLE ALIAS : MSC LENGTH : 2 DERIVATIONS : CWF derives MSC from the following: 1. Date of Birth 2. Claim Through Date 3. Original/Current Reasons for entitlement 4. ESRD Indicator 5. Beneficiary Claim Number Items 1,3,4,5 come from the CWF Beneficiary Master Record; item 2 comes from the FI/Carrier claim record. MSC is assigned as follows: MSC OASI DIB ESRD AGE BIC ______ _____ _____ _____ _____ ______ 10 YES N/A NO 65 and over N/A 11 YES N/A YES 65 and over N/A 20 NO YES NO under 65 N/A 21 NO YES YES under 65 N/A 31 NO NO YES any age T. COMMENTS : Prior to Version H this field was named: BENE_MDCR_STUS_CD. The name has been changed to distinguish this CWF-derived field from the EDB-derived MSC (BENE_MDCR_STUS_CD). SOURCE : CWF CODE TABLE : BENE_MDCR_STUS_TB 47. Claim Patient 6 Position Surname 6 211 216 CHAR The first 6 positions of the Medicare patient's surname (last name) as reported by the provider on the claim. NOTE1: Prior to Version H, this field was only present on the IP/SNF claim record. Effective with Version H, this field is present on all claim types. NOTE2: For OP, HHA, Hospice and all Carrier claims, data was populated beginning with NCH weekly process 10/3/97. Claims processed prior to 10/3/97 will contain spaces in this field. COMMON ALIAS : PATIENT_SURNAME DB2 ALIAS : PTNT_6_PSTN_SRNM SAS ALIAS : SURNAME STANDARD ALIAS : CLM_PTNT_6_PSTN_SRNM_NAME TITLE ALIAS : PATIENT_SURNAME LENGTH : 6 SOURCE : CWF 48. Claim Patient 1st Initial Given Name 1 217 217 CHAR The first initial of the Medicare patient's given name (first name) as reported by the provider on the claim. NOTE1: Prior to Version H, this field was only present on the IP/SNF claim record. Effective with Version H, this field is present on all claim types. NOTE2: For OP, HHA, Hospice and all Carrier claims, data was populated beginning with NCH weekly process date 10/3/97. Claims processed prior to 10/3/97 will contain spaces in this field. COMMON ALIAS : PATIENT_GIVEN_NAME DB2 ALIAS : 1ST_INITL_GVN_NAME SAS ALIAS : FRSTINIT STANDARD ALIAS : CLM_PTNT_1ST_INITL_GVN_NAME TITLE ALIAS : PATIENT_FIRST_INITIAL LENGTH : 1 SOURCE : CWF 49. Claim Patient First Initial Middle Name 1 218 218 CHAR The first initial of the Medicare patient's middle name as reported by the provider on the claim. NOTE1: Prior to Version H, this field was only present on the IP/SNF claim record. Effective with Version H, this field is present on all claim types. NOTE2: For OP, HHA, Hospice and all Carrier claims, data was populated beginning with NCH weekly process date 10/3/97. Claims pro- cessed prior to 10/3/97 will contain spaces in this field. COMMON ALIAS : PATIENT_MIDDLE_NAME DB2 ALIAS : 1ST_INITL_MDL_NAME SAS ALIAS : MDL_INIT STANDARD ALIAS : CLM_PTNT_1ST_INITL_MDL_NAME TITLE ALIAS : PATIENT_MIDDLE_INITIAL LENGTH : 1 SOURCE : CWF 50. Beneficiary CWF Location Code 1 219 219 CHAR The code that identifies the Common Working File (CWF) location (the host site) where a beneficiary's Medicare utilization records are maintained. COMMON ALIAS : CWF_HOST DB2 ALIAS : BENE_CWF_LOC_CD SAS ALIAS : CWFLOCCD STANDARD ALIAS : BENE_CWF_LOC_CD TITLE ALIAS : CWF_HOST LENGTH : 1 SOURCE : CWF CODE TABLE : BENE_CWF_LOC_TB 51. Claim Principal Diagnosis Group 8 220 227 GRP Effective with Version 'J', the group used to identify the principal diagnosis code. This group contains the principal diagnosis code and the principal diagnosis version code. STANDARD ALIAS : CLM_PRNCPAL_DGNS_GRP 52. Claim Principal Diagnosis Version Code 1 220 220 CHAR Effective with Version 'J', the code used to indicate if the diagnosis is ICD-9 or ICD-10. NOTE: With 5010, the diagnosis and procedure codes have been expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013. DB2 ALIAS : UNDEFINED SAS ALIAS : PDVRSNCD STANDARD ALIAS : CLM_PRNCPAL_DGNS_VRSN_CD LENGTH : 1 CODE TABLE : CLM_DGNS_VRSN_TB 53. Claim Principal Diagnosis Code 7 221 227 CHAR The diagnosis code identifying the diagnosis, condition, problem or other reason for the admission/encounter/visit shown in the medical record to be chiefly responsible for the services provided. NOTE: Effective with Version H, this data is also redundantly stored as the first occurrence of the diagnosis trailer. NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. DB2 ALIAS : PRNCPAL_DGNS_CD SAS ALIAS : PDGNS_CD STANDARD ALIAS : CLM_PRNCPAL_DGNS_CD LENGTH : 7 SOURCE : CWF EDIT RULES : ICD-9-CM 54. FILLER 1 228 228 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 1 55. Carrier Claim Payment Denial Code 2 229 230 CHAR The code on a noninstitutional claim indicating to whom payment was made or if the claim was denied. NOTE1: Effective 4/1/02, this field was expanded to two bytes to accommodate new values. The NCH Nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of code for the crosswalk. NOTE2: Effective with Version 'J', the field has been expanded on the NCH record to 2 bytes, With this expansion, the NCH will no longer use the character values to represent the official two byte values sent in by CWF since 4/2002. During the Version J conversion, all character values were converted to the two byte values throughout history.. DB2 ALIAS : CARR_PMT_DNL_CD SAS ALIAS : PMTDNLCD STANDARD ALIAS : CARR_CLM_PMT_DNL_CD LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_CLM_PMT_DNL_CD. CODE TABLE : CARR_CLM_PMT_DNL_TB 56. Claim Excepted/Nonexcepted Medical Treatment Code 1 231 231 CHAR Effective with Version I, the code used to identify whether or not the medical care or treatment received by a beneficiary, who has elected care from a Religious Nonmedical Health Care Institution (RNHCI), is excepted or nonexcepted. Excepted is medical care or treatment that is received involuntarily or is re- quired under Federal, State or local law. Nonexcepted is defined as medical care or treatment other than excepted. DB2 ALIAS : EXCPTD_NEXCPTD_CD SAS ALIAS : TRTMT_CD STANDARD ALIAS : CLM_EXCPTD_NEXCPTD_TRTMT_CD TITLE ALIAS : EXCPTD_NEXCPTD_CD LENGTH : 1 SOURCE : CWF CODE TABLE : CLM_EXCPTD_NEXCPTD_TRTMT_TB 57. Claim Payment Amount 6 232 237 PACK Amount of payment made from the Medicare trust fund for the services covered by the claim record. Generally, the amount is calculated by the FI or carrier; and represents what was paid to the institutional provider, physician, or supplier, with the exceptions noted below. ***NOTE: In some situations, a negative claim payment amount may be pre- sent; e.g., (1) when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or (2) when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.) Under IP PPS, inpatient hospital services are paid based on a predetermined rate per discharge, using the DRG patient classification system and the PRICER program. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (since 5/1/86), indirect medical education (since 10/1/88), total PPS capital (since 10/1/91). After 4/1/03, the payment amount could also include a "new technology" add-on amount. After 7/5/2011, the payment amount could also include a payment adjustment given to hospitals to account for the higher costs per discharge for "low-income hospitals". After 10/1/2012, the payment amount could also include adjustments for value based purchasing, readmissions, and Model 1, Bundled Payments for Care Improvement. After 10/1/2014, the payment amount could also include the uncompensated care payment (UCP). It does NOT include the pass-thru amounts (i.e., capital- related costs, direct medical education costs, kidney acquisition costs, bad debts); or any beneficiary-paid amounts (i.e., deductibles and coinsurance); or any any other payer reimbursement. Under IRFPPS, inpatient rehabilitation services are paid based on a predetermined rate per discharge, using the Case Mix Group (CMG) classification system and the PRICER program. From the CMG on the IRF PPS claim, payment is based on a standard payment amount for operating and capital cost for that facility (including routine and ancillary services). The payment is adjusted for wage, the % of low-income patients (LIP), locality, transfers, interrupted stays, short stay cases, deaths, and high cost outliers. Some or all of these adjustments could apply. The CMG payment does NOT include certain pass- through costs (i.e. bad debts, approved education activities); beneficiary-paid amounts, other payer reim- bursement,and other services outside of the scope of PPS. Under LTCH PPS, long term care hospital services are paid based on a predetermined rate per discharge based on the DRG and the PRICER program. Payments are based on a single standard Federal rate for both inpatient operating and capital-related costs (including routine and ancillary services), but do NOT include certain pass-through costs (i.e. bad debts, direct medical education, new technologies and blood clotting factors). Adjustments to the payment may occur due to short-stay outliers, interrupted stays, high cost outliers, wage index, and cost of living adjust- ments. Under SNF PPS, SNFs will classify beneficiaries using the patient classification system known as RUGS III. For the SNF PPS claim, the SNF PRICER will calculate/return the rate for each revenue center line item with revenue center code = '0022'; multiply the rate times the units count; and then sum the amount payable for all lines with revenue center code '0022' to determine the total claim payment amount. Under Outpatient PPS, the national ambulatory payment classification (APC) rate that is calculated for each APC group is the basis for determining the total claim payment. The payment amount also includes the outlier payment and interest. Under Home Health PPS, beneficiaries will be classified into an appropriate case mix category known as the Home Health Resource Group. A HIPPS code is then generated corresponding to the case mix category (HHRG). For the RAP, the PRICER will determine the payment amount appropriate to the HIPPS code by computing 60% (for first episode) or 50% (for subsequent episodes) of the case mix episode payment. The payment is then wage index adjusted. For the final claim, PRICER calculates 100% of the amount due, because the final claim is processed as an adjustment to the RAP, reversing the RAP payment in full. Although final claim will show 100% payment amount, the provider will actually receive the 40% or 50% payment. The payment may also include outlier payments. Exceptions: For claims involving demos and BBA encounter data, the amount reported in this field may not just represent the actual provider payment. For demo Ids '01','02','03','04' -- claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included. For demo Ids '05','15' -- encounter data 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO. For demo Ids '06','07','08' -- claims contain actual provider payment but represent a special negotiated bundled payment for both Part A and Part B services. To identify what the conventional provider Part A payment would have been, check value code = 'Y4'. The related noninstitutmonal (physician/supplier) claims contain what would have been paid had there been no demo. For BBA encounter data (non-demo) -- 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan. COMMON ALIAS : REIMBURSEMENT DB2 ALIAS : CLM_PMT_AMT SAS ALIAS : PMT_AMT STANDARD ALIAS : CLM_PMT_AMT TITLE ALIAS : REIMBURSEMENT LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H, the size of this field was S9(7)V99. Also, the noninstitutional claim records carried this field as a line item. Effective with Version H, this element is a claim level field across all claim types (and the line item field has been renamed.) SOURCE : CWF LIMITATIONS : REFER TO : PMT_AMT_EXCEDG_CHRG_AMT_LIM EDIT RULES : $$$$$$$$$CC 58. Carrier Claim Primary Payer Paid Amount 6 238 243 PACK Effective with Version H, the amount of a payment made on behalf of a Medicare bene- ficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges on a non-institutional claim. NOTE: During the Version H conversion, this field was populated with data throughout history (back to service year 1991) by summing up the line item primary payer amounts. DB2 ALIAS : CARR_PRMRY_PYR_AMT SAS ALIAS : PRPAYAMT STANDARD ALIAS : CARR_CLM_PRMRY_PYR_PD_AMT TITLE ALIAS : PRIMARY_PAYER_AMOUNT LENGTH : 9.2 SIGNED : Y SOURCE : CWF EDIT RULES : $$$$$$$$$CC 59. FILLER 1 244 244 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 1 60. DMERC Claim Ordering Physician UPIN Number 6 245 250 CHAR Effective with Version G, the unique physician identification number (UPIN) of the physician ordering the Part B services/DMEPOS item. DB2 ALIAS : ORDRG_PHYSN_UPIN SAS ALIAS : ORD_UPIN STANDARD ALIAS : DMERC_CLM_ORDRG_PHYSN_UPIN_NUM TITLE ALIAS : ORDRG_UPIN LENGTH : 6 COMMENTS : Prior to Version H this field was named: CWFB_CLM_ORDRG_PHYSN_UPIN_NUM. SOURCE : CWF 61. DMERC Claim Ordering Physician NPI Number 10 251 260 CHAR The National Provider Identifier (NPI) assigned to the physician ordering the Part B/DMEPOS line item. NOTE: Effective May 2007, the NPI will become the national standard identifier for covered health care providers. NPIs will replace the current legacy provider numbers (UPINs, NPIs, OSCAR provider numbers, etc.) on the standard HIPAA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capa- bility was there for the NCH to receive NPIs along with an existing legacy number. NOTE1: CMS has determined that dual provider identifiers (legacy numbers and NPIs) must be available on the NCH. After the 5/07 NPI implementation, the standard system maintainers will add the legacy number to the claim when it is adjudicated. Effective May 2007, no NEW UPINs (legacy number) will be generated for NEW physi- cians (Part B and Outpatient claims) so there will only be NPIs sent in to the NCH for those physicians. COMMON ALIAS : ORDERING_PHYSICIAN_NPI DB2 ALIAS : ORDRG_PHYSN_NPI SAS ALIAS : ORD_NPI STANDARD ALIAS : DMERC_CLM_ORDRG_PHYSN_NPI_NUM TITLE ALIAS : ORDRG_NPI LENGTH : 10 SOURCE : CWF 62. Carrier Claim Provider Assignment Indicator Switch 1 261 261 CHAR A switch indicating whether or not the provider accepts assignment for the noninstitutional claim. DB2 ALIAS : PRVDR_ASGNMT_SW SAS ALIAS : ASGMNTCD STANDARD ALIAS : CARR_CLM_PRVDR_ASGNMT_IND_SW TITLE ALIAS : ASSIGNMENT_SW LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_CLM_PRVDR_ASGNMT_IND_SW. SOURCE : CWF CODE TABLE : CARR_CLM_PRVDR_ASGNMT_IND_TB 63. NCH Claim Provider Payment Amount 6 262 267 PACK Effective with Version H, the total payments made to the provider for this claim (sum of line item provider payment amounts.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : NCH_PRVDR_PMT_AMT SAS ALIAS : PROV_PMT STANDARD ALIAS : NCH_CLM_PRVDR_PMT_AMT TITLE ALIAS : PRVDR_PMT LENGTH : 9.2 SIGNED : Y SOURCE : NCH QA Process 64. NCH Claim Beneficiary Payment Amount 6 268 273 PACK Effective with Version H, the total payments made to the beneficiary for this claim (sum of line payment amounts to the beneficiary.) NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : NCH_BENE_PMT_AMT SAS ALIAS : BENE_PMT STANDARD ALIAS : NCH_CLM_BENE_PMT_AMT TITLE ALIAS : BENE_PMT LENGTH : 9.2 SIGNED : Y SOURCE : NCH QA Process 65. Carrier Claim Beneficiary Paid Amount 6 274 279 PACK Effective with Version H, the amount paid by the beneficiary for the non-institutional Part B services. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : CARR_BENE_PD_AMT SAS ALIAS : BENEPAID STANDARD ALIAS : CARR_CLM_BENE_PD_AMT TITLE ALIAS : BENE_PD_AMT LENGTH : 9.2 SIGNED : Y SOURCE : CWF 66. NCH Carrier Claim Submitted Charge Amount 6 280 285 PACK Effective with Version H, the total submitted charges on the claim (the sum of line item submitted charges). NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : CARR_SBMT_CHRG_AMT SAS ALIAS : SBMTCHRG STANDARD ALIAS : NCH_CARR_SBMT_CHRG_AMT TITLE ALIAS : SBMT_CHRG LENGTH : 9.2 SIGNED : Y SOURCE : NCH QA Process EDIT RULES : $$$$$$$$$CC 67. NCH Carrier Claim Allowed Charge Amount 6 286 291 PACK Effective with Version H, the total allowed charges on the claim (the sum of line item allowed charges). NOTE1: The amount includes beneficiary-paid amounts (i.e., deductible and coinsurance). NOTE2: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : CARR_ALOW_CHRG_AMT SAS ALIAS : ALOWCHRG STANDARD ALIAS : NCH_CARR_ALOW_CHRG_AMT TITLE ALIAS : ALOW_CHRG LENGTH : 9.2 SIGNED : Y SOURCE : NCH QA Process EDIT RULES : $$$$$$$CC 68. Carrier Claim Cash Deductible Applied Amount 6 292 297 PACK Effective with Version H, the amount of the cash deductible as submitted on the claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : CASH_DDCTBL_AMT SAS ALIAS : DEDAPPLY STANDARD ALIAS : CARR_CLM_CASH_DDCTBL_APPLY_AMT TITLE ALIAS : CASH_DDCTBL LENGTH : 9.2 SIGNED : Y SOURCE : CWF 69. Carrier Claim HCPCS Year Code 1 298 298 NUM Effective with Version H, the terminal digit of HCPCS version used to code the claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : CARR_HCPCS_YR_CD SAS ALIAS : HCPCS_YR STANDARD ALIAS : CARR_CLM_HCPCS_YR_CD TITLE ALIAS : HCPCS_YR LENGTH : 1 SIGNED : N SOURCE : CWF 70. Carrier Claim MCO Override Indicator Code 1 299 299 CHAR Effective with Version H, the code used to indicate whether or not an MCO investigation applies to the claim (used for internal CWFMQA editing purposes). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : MCO_OVRRD_IND_CD SAS ALIAS : MCOOVRRD STANDARD ALIAS : CARR_CLM_MCO_OVRRD_IND_CD TITLE ALIAS : MCO_OVERRIDE LENGTH : 1 SOURCE : CWF CODE TABLE : CARR_CLM_MCO_OVRRD_IND_TB 71. Carrier Claim Hospice Override Indicator Code 1 300 300 CHAR Effective with Version H, the code used to indicate whether or not an Hospice investigation applies to the claim (used for internal CWFMQA editing purposes). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : HOSPC_OVRRD_IND_CD SAS ALIAS : HOSPOVRD STANDARD ALIAS : CARR_CLM_HOSPC_OVRRD_IND_CD TITLE ALIAS : HOSPC_OVERRIDE LENGTH : 1 SOURCE : CWF CODE TABLE : CARR_CLM_HOSPC_OVRRD_IND_TB 72. Claim Business Segment Identifier Code 4 301 304 CHAR Effective 10/1/2005 with the implementation of NCH/NMUD CR#2, the identifier that captures the 2-byte juris- diction code (represents the USPS state/territory abbreviation (i.e. NY = New York) and the 2-byte modifier that identifies the type of Medicare FFS contract (intermediary, RHHI, carrier or DMERC). This 4-byte identifier along with the 5-byte FI/Carrier number comprises the Contractor Workload Identifier number. The business segment identifier (BSI) is intended to help sort work- loads that may be redistributed with the implemen- tation of contracting reform as required by MMA. DB2 ALIAS : BUSNS_SGMT_ID_CD SAS ALIAS : SGMT_ID STANDARD ALIAS : CLM_BUSNS_SGMT_ID_CD LENGTH : 4 SOURCE : CWF 73. Claim Clinical Trial Number 8 305 312 CHAR Effective September 1, 2008 with the implementation of CR#3, the number used to identify all items and services provided to a beneficiary during their participation in a clinical trial. NOTE: CMS is requesting the clinical trial number be voluntarily reported. The number is assigned by the National Library of Medicine (NLM) Clinical Trials Data Bank when a new study is registered. DB2 ALIAS : CLM_CLNCL_TRIL_NUM SAS ALIAS : CTRILNUM STANDARD ALIAS : CLM_CLNCL_TRIL_NUM LENGTH : 8 74. Recovery Audit Contractor (RAC) Adjustment Indicator Code 1 313 313 CHAR Effective January 5, 2009 with the implementation of CR#4, the code used to identify a Recovery Audit Contractor (RAC) requested adjustment. This occurs as a result of post-payment review activities done by the RAC. DB2 ALIAS : RAC_ADJSTMT_CD SAS ALIAS : RACINDCD STANDARD ALIAS : CLM_RAC_ADJSTMT_IND_CD LENGTH : 1 CODE TABLE : CLM_RAC_ADJSTMT_TB 75. Claim Paperwork (PWK) Code 2 314 315 CHAR Effective with CR#6, the code used to indicate a provider has submitted an electronic claim that requires additional documentation. DB2 ALIAS : CLM_PWK_CD STANDARD ALIAS : CLM_PWK_CD LENGTH : 2 CODE TABLE : CLM_PWK_TB 76. Claim Care Improvement Model 1 Code 2 316 317 CHAR Effective with CR#7, the code used to identify that the care improvement model 1 is being used for bundling payments. The valid value for care improvement model 1 is '61'. DB2 ALIAS : CARE_MODEL_1_CD SAS ALIAS : CMODEL1 STANDARD ALIAS : CLM_CARE_IMPRVMT_MODEL_1_CD LENGTH : 2 CODE TABLE : CLM_CARE_IMPRVMT_MODEL_TB 77. Claim Care Improvement Model 2 Code 2 318 319 CHAR Effective with CR#7, the code used to identify that the care improvement model 2 is being used for bundling payments. The valid value for care improvement model 2 is '62'. DB2 ALIAS : CARE_MODEL_2_CD SAS ALIAS : CMODEL2 STANDARD ALIAS : CLM_CARE_IMPRVMT_MODEL_2_CD LENGTH : 2 CODE TABLE : CLM_CARE_IMPRVMT_MODEL_TB 78. Claim Care Improvement Model 3 Code 2 320 321 CHAR Effective with CR#7, the code used to identify that the care improvement model 3 is being used for bundling payments. The valid value for care improvement model 3 is '63'. DB2 ALIAS : CARE_MODEL_3_CD SAS ALIAS : CMODEL3 STANDARD ALIAS : CLM_CARE_IMPRVMT_MODEL_3_CD LENGTH : 2 CODE TABLE : CLM_CARE_IMPRVMT_MODEL_TB 79. Claim Care Improvement Model 4 Code 2 322 323 CHAR Effective with CR#7, the code used to identify that the care improvement model 4 is being used for bundling payments. The valid value for care improvement model 4 is '64'. DB2 ALIAS : CARE_MODEL_4_CD SAS ALIAS : CMODEL4 STANDARD ALIAS : CLM_CARE_IMPRVMT_MODEL_4_CD LENGTH : 2 CODE TABLE : CLM_CARE_IMPRVMT_MODEL_TB 80. Claim Fraud Prevention System (FPS) Model Number 2 324 325 CHAR Effective with Version 'K', this field identifies an FPS analytic model that identifies claims that may be high risk for fraud based on specific information. DB2 ALIAS : CLM_FPS_MODEL_NUM SAS ALIAS : FPSMODEL STANDARD ALIAS : CLM-FPS-MODEL-NUM LENGTH : 2 COMMENTS : Valid Values: 0 - 9, A -Z 81. Claim FPS Reason Code 3 326 328 CHAR Effective with Version 'K', this field identifies the reason codes used to explain why a claim was not paid or how the claim was paid. These codes also show the reason for any claim financial adjustment such as denial, reductions or increases in payment. DB2 ALIAS : CLM_FPS_RSN_CD SAS ALIAS : FPSRSN STANDARD ALIAS : CLM_FPS_RSN_CD LENGTH : 3 CODE TABLE : CLM_ADJ_RSN_TB 82. Claim FPS Remarks Code 5 329 333 CHAR Effective with Version 'K', the codes used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. DB2 ALIAS : CLM_FPS_RMRK_CD SAS ALIAS : FPSRMRK STANDARD ALIAS : CLM_FPS_RMRK_CD LENGTH : 5 CODE TABLE : CLM_RMTNC_ADVC_TB 83. Claim FPS MSN 1 Code 5 334 338 CHAR Effective with Version 'K', the field used to identify the Medicare Secondary Notice Code. DB2 ALIAS : CLM_FPS_MSN_1_CD SAS ALIAS : FPSMSN1 STANDARD ALIAS : CLM-FPS-MSN-1-CD LENGTH : 5 CODE TABLE : CLM_FPS_MSN_CD_TB 84. Claim FPS MSN 2 Code 5 339 343 CHAR Effective with Version 'K', the field used to identify the Medicare Secondary Notice Code. DB2 ALIAS : CLM_FPS_MSN_2_CD SAS ALIAS : FPSMSN2 STANDARD ALIAS : CLM-FPS-MSN-2-CD LENGTH : 5 CODE TABLE : CLM_FPS_MSN_CD_TB 85. Claim Mass Adjustment Indicator Code 1 344 344 CHAR Effective with Version 'K', the field used to identify if the adjustment claim is part of a mass adjustment project. DB2 ALIAS : MASS_ADJSTMT_CD SAS ALIAS : MADJSTMT STANDARD ALIAS : CLM_MASS_ADJSTMT_IND_CD LENGTH : 1 CODE TABLE : CLM_MASS_ADJSTMT_IND_CD_TB 86. DMERC Claim National Mail Order (NMO) Competitive Bidding Area (CBA) Indicator Code 5 345 349 CHAR Effective with CR#8, the field used to identify when a beneficiary does not reside in a competitive bidding area (CBA) and at least one line on the claim is subject to National Mail Order (NMO) pro- gram. DB2 ALIAS : DMERC_NMO_CBA_CD SAS ALIAS : NMOIND STANDARD ALIAS : DMERC_CLM_NMO_CBA_CD LENGTH : 5 CODE TABLE : DMERC_CLM_NMO_CBA_IND_TB 87. Claim Paper Provider Code 2 350 351 CHAR Effective with CR#8, the code used to identify the provider type that submitted the paper claim. NOTE: This data element will not be implemented in CWF until the January 2014 release, which means you will not begin to see data in this field in the NCH until the January implementation. We are adding this field with the NCH CR#8 October release because we will not be doing a January 2014 release. DB2 ALIAS : CLM_PAPER_PRVDR_CD SAS ALIAS : PPRVDR STANDARD ALIAS : CLM_PAPER_PRVDR_CD LENGTH : 2 CODE TABLE : CLM_PAPER_PRVDR_TB 88. Claim Residual Payment Indicator Code 1 352 352 CHAR Effective with CR#11, this field is used by CWF claims processing for the purpose of bypassing its normal MSP editing that would otherwise apply for ongoing responsibility for medicals (ORM) or worker's compensation Medicare Set-Aside Arrangements (WCMSA). Normally, CWF does not allow a secondary payment on MSP involving ORM or WCMSA, so the residual payment indicator will be used to allow CWF to make an exception to its normal routine. DB2 ALIAS : CLM_RSDL_PMT_CD SAS ALIAS : RSDLPMT STANDARD ALIAS : CLM_RSDL_PMT_IND_CD LENGTH : 1 SOURCE : CWF CODE TABLE : RSDL_PMT_IND_TB 89. Claim Accountable Care Organization (ACO) Identification Number 10 353 362 CHAR Effective with CR#12, this field identifies the unique identifi- cation number assigned to the Accountable Care Organization (ACO). DB2 ALIAS : CLM_ACO_ID_NUM SAS ALIAS : ACOIDNUM STANDARD ALIAS : CLM_ACO_ID_NUM LENGTH : 10 COMMENTS : (CMS CR9468) - CWF July 2016 Release 90. Medicare Beneficiary Identification (MBI) Number 11 363 373 CHAR Effective with CR#12, this field represents the Medicare beneficiary identification number. This field is being added due to the removal of the Social Security Number from the Medicare card (SSNRI project). The MBI will replace the HICN on the Medicare card. CMS will continue to use the HICN within internal systems. NOTE: We will not see MBI's on the claims until October 2017 (start of the transition period). DB2 ALIAS : MBI_ID SAS ALIAS : MBIID STANDARD ALIAS : MBI_ID LENGTH : 11 COMMENTS : SSNRI Project CWF October 2017 Release 91. Claim Beneficiary Identifier Type Code 1 374 374 CHAR Effective with CR#12, this field identifies whether the claim was submitted by the provider, during the transition period, with a HICN or MBI. NOTE: This field will not be populated with data until the start of the transition period (October 2017). DB2 ALIAS : BENE_ID_TYPE_CD SAS ALIAS : BENEIDCD STANDARD ALIAS : CLM_BENE_ID_TYPE_CD LENGTH : 1 COMMENTS : (SSNRI Project) CWF October 2017 Release CODE TABLE : CLM_BENE_ID_TYPE_TB 92. FILLER 670 375 1044 CHAR DB2 ALIAS : H_FILLER_7 LENGTH : 670 93. DMERC NCH Edit Code Count 2 1045 1046 NUM The count of the number of edit codes annotated to the DMERC claim during HCFA's CWFMQA process. The purpose of this count is to indicate how many claim edit trailers are present. Prior to Version H this field was named: CLM_EDIT_CD_CNT. DB2 ALIAS : EDIT_TRLR_CNT SAS ALIAS : DEDCNT STANDARD ALIAS : DMERC_NCH_EDIT_CD_CNT LENGTH : 2 SIGNED : N COMMENTS : Prior to Version H this field was named: CLM_EDIT_CD_CNT. SOURCE : NCH 94. DMERC NCH Patch Code Count 2 1047 1048 NUM Effective with Version H, the count of the number of HCFA patch codes annotated to the DMERC claim during the Nearline maintenance process. The purpose of this count is to indicate how many NCH patch trailers are present. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : DMERC_PATCH_CD_CNT SAS ALIAS : DPATCNT STANDARD ALIAS : DMERC_NCH_PATCH_CD_I_CNT LENGTH : 2 SIGNED : N SOURCE : NCH 95. DMERC MCO Period Count 1 1049 1049 NUM Effective with Version H, the count of the number of Managed Care Organization (MCO) periods reported on a DMERC claim. The purpose of this count is to indicate how many MCO period trailers are present. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : DMERC_MCO_PRD_CNT SAS ALIAS : DMCOCNT STANDARD ALIAS : DMERC_MCO_PRD_CNT LENGTH : 1 SIGNED : N SOURCE : NCH EDIT RULES : RANGE: 0 TO 2 96. DMERC Claim Demonstration ID Count 1 1050 1050 NUM Effective with Version H, the count of the number of claim demonstration IDs reported on an DMERC claim. The purpose of this count is to indicate how many claim demonstration trailers are present. NOTE: During the Version H conversion this field was populated with data where a demo was identifiable. DB2 ALIAS : DEMO_TRLR_CNT SAS ALIAS : DDEMCNT STANDARD ALIAS : DMERC_CLM_DEMO_ID_CNT LENGTH : 1 SIGNED : N SOURCE : NCH EDIT RULES : RANGE: 0 TO 5 97. DMERC Claim Diagnosis Code Count 2 1051 1052 NUM The count of the number of diagnosis codes (both principal and secondary) reported on a DMERC claim. The purpose of this count is to indicate how many claim diagnosis code trailers are present. NOTE: Effective with Version 'J', the count of the number of diagnosis code trailers was expanded from 8 to 12. DB2 ALIAS : DGNS_TRLR_CNT SAS ALIAS : DDGNCNT STANDARD ALIAS : DMERC_CLM_DGNS_CD_J_CNT LENGTH : 2 SIGNED : N COMMENTS : Prior to Version H this field was named: CLM_DGNS_CD_CNT. SOURCE : NCH EDIT RULES : RANGE: 0 TO 12 98. DMERC Claim Line Count 2 1053 1054 NUM The count of the number of line items reported on the DMERC claim. The purpose of this count is to indicate how many line item trailers are present. DB2 ALIAS : LINE_ITM_TRLR_CNT SAS ALIAS : DLINECNT STANDARD ALIAS : DMERC_CLM_LINE_CNT LENGTH : 2 SIGNED : N COMMENTS : Prior to Version H this field was named: CWFB_CLM_NUM_LINE_ITM_CNT. SOURCE : CWFB CLAIMS EDIT RULES : RANGE: 1 TO 13 99. FILLER 4 1055 1058 CHAR DB2 ALIAS : FILLER STANDARD ALIAS : FILLER LENGTH : 4 100. DMERC Claim Variable Group VAR 1059 18927 GRP 101. NCH Edit Group 65 1059 1123 GRP The number of claim edit trailers is determined by the claim edit code count. STANDARD ALIAS : NCH_EDIT_GRP OCCURS MIN: 0 OCCURS MAX: 13 DEPENDING ON : DMERC_NCH_EDIT_CD_CNT 102. NCH Edit Trailer Indicator Code 1 1059 1059 CHAR Effective with Version H, the code indicating the presence of an NCH edit trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS : EDIT_TRLR_IND_CD SAS ALIAS : EDITIND STANDARD ALIAS : NCH_EDIT_TRLR_IND_CD LENGTH : 1 SOURCE : NCH QA Process CODE TABLE : NCH_EDIT_TRLR_IND_TB 103. NCH Edit Code 4 1060 1063 CHAR The code annotated to the claim indicating the CWFMQA editing results so users will be aware of data deficiencies. NOTE: Prior to Version H only the highest priority code was stored. Beginning 11/98 up to 13 edit codes may be present. COMMON ALIAS : QA_ERROR_CODE DB2 ALIAS : NCH_EDIT_CD SAS ALIAS : EDIT_CD STANDARD ALIAS : NCH_EDIT_CD TITLE ALIAS : QA_ERROR_CD LENGTH : 4 SOURCE : NCH QA EDIT PROCESS CODE TABLE : NCH_EDIT_TB 104. NCH Patch Group 330 1124 1453 GRP STANDARD ALIAS : NCH_PATCH_GRP OCCURS MIN: 0 OCCURS MAX: 30 DEPENDING ON : DMERC_NCH_PATCH_CD_I_CNT 105. NCH Patch Trailer Indicator Code 1 1124 1124 CHAR Effective with Version H, the code indicating the presence of an NCH patch trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS : PATCH_TRLR_IND_CD SAS ALIAS : PATCHIND STANDARD ALIAS : NCH_PATCH_TRLR_IND_CD LENGTH : 1 SOURCE : NCH CODE TABLE : NCH_PATCH_TRLR_IND_TB 106. NCH Patch Code 2 1125 1126 CHAR Effective with Version H, the code annotated to the claim indicating a patch was applied to the record during an NCH Nearline record conversion and/or during current processing. NOTE: Prior to Version H this field was located in the third and fourth occurrence of the CLM_EDIT_CD. DB2 ALIAS : NCH_PATCH_CD SAS ALIAS : PATCHCD STANDARD ALIAS : NCH_PATCH_CD TITLE ALIAS : NCH_PATCH LENGTH : 2 SOURCE : NCH CODE TABLE : NCH_PATCH_TB 107. NCH Patch Applied Date 8 1127 1134 NUM Effective with Version H, the date the NCH patch was applied to the claim. DB2 ALIAS : NCH_PATCH_APPLY_DT SAS ALIAS : PATCHDT STANDARD ALIAS : NCH_PATCH_APPLY_DT TITLE ALIAS : NCH_PATCH_DT LENGTH : 8 SIGNED : N SOURCE : NCH EDIT RULES : YYYYMMDD 108. MCO Period Group 74 1454 1527 GRP The number of managed care organization (MCO) period data trailers present is determined by the claim MCO period trailer count. This field reflects the two most current MCO periods in the CWF beneficiary history record. It may have no connection to the services on the claim. STANDARD ALIAS : MCO_PRD_GRP OCCURS MIN: 0 OCCURS MAX: 2 DEPENDING ON : DMERC_MCO_PRD_CNT 109. NCH MCO Trailer Indicator Code 1 1454 1454 CHAR Effective with Version H, the code indicating the presence of a Managed Care Organization (MCO) trailer. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : MCO_TRLR_IND_CD SAS ALIAS : MCOIND STANDARD ALIAS : NCH_MCO_TRLR_IND_CD TITLE ALIAS : MCO_INDICATOR LENGTH : 1 SOURCE : NCH QA Process CODE TABLE : NCH_MCO_TRLR_IND_TB 110. MCO Contract Number 5 1455 1459 CHAR Effective with Version H, this field represents the plan contract number of the Managed Care Organization (MCO). NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : MCO_CNTRCT_NUM SAS ALIAS : MCONUM STANDARD ALIAS : MCO_CNTRCT_NUM TITLE ALIAS : MCO_NUM LENGTH : 5 SOURCE : CWF 111. MCO Option Code 1 1460 1460 CHAR Effective with Version H, the code indicating Managed Care Organization (MCO) lock-in enrollment status of the beneficiary. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. DB2 ALIAS : MCO_OPTN_CD SAS ALIAS : MCOOPTN STANDARD ALIAS : MCO_OPTN_CD TITLE ALIAS : MCO_OPTION_CD LENGTH : 1 SOURCE : CWF CODE TABLE : MCO_OPTN_TB 112. MCO Period Effective Date 8 1461 1468 NUM Effective with Version H, the date the bene- ficiary's enrollment in the Managed Care Organization (MCO) became effective. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : MCO_PRD_EFCTV_DT SAS ALIAS : MCOEFFDT STANDARD ALIAS : MCO_PRD_EFCTV_DT TITLE ALIAS : MCO_PERIOD_EFF_DT LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 113. MCO Period Termination Date 8 1469 1476 NUM Effective with Version H, the date the bene- ficiary's enrollment in the Managed Care Organization (MCO) was terminated. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : MCO_PRD_TRMNTN_DT SAS ALIAS : MCOTRMDT STANDARD ALIAS : MCO_PRD_TRMNTN_DT TITLE ALIAS : MCO_PERIOD_TERM_DT LENGTH : 8 SIGNED : N SOURCE : CWF EDIT RULES : YYYYMMDD 114. MCO Health PLANID Number 14 1477 1490 CHAR A placeholder field (effective with Version H) for storing the Health PlanID associated with the Managed Care Organization (MCO). Prior to Version 'I' this field was named: MCO_PAYERID_NUM. DB2 ALIAS : MCO_PLANID_NUM SAS ALIAS : MCOPLNID STANDARD ALIAS : MCO_HLTH_PLANID_NUM TITLE ALIAS : MCO_PLANID LENGTH : 14 COMMENTS : Prior to Version I this field was named: MCO_PAYERID_NUM. SOURCE : CWF 115. Claim Demonstration Identification Group 90 1528 1617 GRP The number of demonstration identification trailers present is determined by the claim demonstration identification trailer count. STANDARD ALIAS : CLM_DEMO_ID_GRP OCCURS MIN: 0 OCCURS MAX: 5 DEPENDING ON : DMERC_CLM_DEMO_ID_CNT 116. NCH Demonstration Trailer Indicator Code 1 1528 1528 CHAR Effective with Version H, the code indicating the presence of a demo trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS : NCH_DEMO_TRLR_IND_ SAS ALIAS : DEMOIND STANDARD ALIAS : NCH_DEMO_TRLR_IND_CD TITLE ALIAS : DEMO_INDICATOR LENGTH : 1 SOURCE : NCH CODE TABLE : NCH_DEMO_TRLR_IND_TB 117. Claim Demonstration Identification Number 2 1529 1530 CHAR Effective with Version H, the number assigned to identify a demo. This field is also used to denote special processing (a.k.a. Special Processing Number, SPN). NOTE: Prior to Version H, Demo ID was stored in the redefined Claim Edit Group, 4th occurrence, positions 3 and 4. During the H conversion, this field was populated with data throughout history (as appro- private either by moving ID on Version G or by deriving from specific demo criteria). 01 = Nursing Home Case-Mix and Quality: NHCMQ (RUGS) Demo -- testing PPS for SNFs in 6 states, using a case-mix classification system based on resident characteristics and actual resources used. The claims carry a RUGS indicator and one or more revenue center codes in the 9,000 series. NOTE1: Effective for SNF claims with NCH weekly process date after 2/8/96 (and service date after 12/31/95) -- beginning 4/97, Demo ID '01' was derived in NCH based on presence of RUGS phase # '2','3' or '4' on incoming claim; since 7/97, CWF has been adding ID to claim. NOTE2: During the Version H conversion, Demo ID '01' was populated back to NCH weekly process date 2/9/96 based on the RUGS phase indicator (stored in Claim Edit Group, 3rd occurrence, 4th position, in Version G). 02 = National HHA Prospective Payment Demo -- testing PPS for HHAs in 5 states, using two alternate methods of paying HHAs: per visit by type of HHA visit and per episode of HH care. NOTE1: Effective for HHA claims with NCH weekly process date after 5/31/95 -- beginning 4/97, Demo ID '02' was derived in NCH based on HCFA/ CHPP-supplied listing of provider # and start/ stop dates of participants. NOTE2: During the Version H conversion, Demo ID '02' was populated back to NCH weekly process date 6/95 based on the CHPP criteria. 03 = Telemedicine Demo -- testing covering tradi- tionally noncovered physician services for medical consultation furnished via two-way, inter- active video systems (i.e. teleconsultation) in 4 states. The claims contain line items with 'QQ' HCPCS code. NOTE1: Effective for physician/supplier (nonDMERC) claims with NCH weekly process date after 12/31/96 (and service date after 9/30/96) -- since 7/97, CWF has been adding Demo ID '03' to claim. NOTE2: During Version H conversion, Demo ID '03' was populated back to NCH weekly process date 1/97 based on the presence of 'QQ' HCPCS on one or more line items. 04 = United Mine Workers of America (UMWA) Managed Care Demo -- testing risk sharing for Part A services, paying special capitation rates for all UMWA beneficiaries residing in 13 desig- nated counties in 3 states. Under the demo, UMWA will waive the 3-day qualifying hospital stay for a SNF admission. The claims contain TOB '18X','21X','28X' and '51X'; condition code = W0; claim MCO paid switch = not '0'; and MCO contract # = '90091'. NOTE: Initially scheduled to be implemented for all SNF claims for admission or services on 1/1/97 or later, CWF did not transmit any Demo ID '04' annotated claims until on or about 2/98. 05 = Medicare Choices (MCO encounter data) demo -- testing expanding the type of Managed Care plans available and different payment methods at 16 MCOs in 9 states. The claims contain one of the specific MCO Plan Contract # assigned to the Choices Demo site. NOTE1: Effective for all claim types with NCH weekly process date after 7/31/97 -- CWF adds Demo ID '05' to claim based on the presence of the MCO Plan Contract #. ***Demonstration was terminated 12/31/2000.*** NOTE2: During the Version H conversion, Demo ID '05' was populated back to NCH weekly process date 8/97 based on the presence of the Choices indicator (stored as an alpha character cross- walked from MCO plan contract # in the Claim Edit Group, 4th occurrence, 2nd position, in Version 'G'). 06 = Coronary Artery Bypass Graft (CABG) Demo -- testing bundled payment (all-inclusive global pricing) for hospital + physician services related to CABG surgery in 7 hospitals in 7 states. The inpatient claims contain a DRG '106' or '107'. NOTE1: Effective for Inpatient claims and physician/supplier claims with Claim Edit Date no earlier than 6/1/91 (not all CABG sites started at the same time) -- on 5/1/97, CWF started transmitting Demo ID '06' on the claim. The FI adds the ID to the claim based on the presence of DRG '106' or '107' from specific providers for specified time periods; the carrier adds the ID to the claim based on receiving 'Daily Census List' from parti- cipating hospitals. ***Demo terminated in 1998.*** NOTE2: During the Version H conversion, any claims where Medicare is the primary payer that were not already identified as Demo ID '06' (stored in the redefined Claim Edit Group, 4th occurrence, positions 3 and 4, Version G) were annotated based on the follow- ing criteria: Inpatient - presence of DRG '106' or '107' and a provider number=220897, 150897, 380897,450897,110082,230156 or 360085 for specified service dates; noninstitutional - presence of HCPCS modifier (initial and/or second) = 'Q2' and a carrier number =00700/31143 00630,01380,00900,01040/00511,00710,00623, or 13630 for specified service dates. 07 = Virginia Cardiac Surgery Initiative (VCSI) (formerly referred to as Medicare Quality Partner- ships Demo) -- this is a voluntary consortium of the cardiac surgery physician groups and the non- Veterans Administration hospitals providing open heart surgical services in the Commonwealth of Virginia. The goal of the demo is to share data on quality and process innovations in an attempt to improve the care for all cardiac patients. The demonstration only affects those FIs that process claims from hospitals in Virginia and the carriers that process claims from physicians providing inpatient services at those hospitals. The hospitals will be reimbursed on a global payment basis for selected cardiac surgical diagnosis related groups (DRGs). The inpatient claims will contain a DRG '104', '105', '106', '107', '109'; the related physician/supplier claims will contain the claim payment denial reason code = 'D'. NOTE: The implementation date for this demo is 4/1/03. The FI will annotate the claim with the demo id add Demo ID '07' to claim. For carrier claims, the Standard Systems will annotate the claim with the '07' demo number. 08 = Provider Partnership Demo -- testing per-case payment approaches for acute inpatient hospitalizations, making a lump-sum payment (combining the normal Part A PPS payment with the Part B allowed charges into a single fee schedule) to a Physician/Hospital Organization for all Part A and Part B services associated with a hospital admission. From 3 to 6 hospitals in the Northeast and Mid-Atlantic regions may participate in the demo. NOTE: The demo is on HOLD. The FI and carrier will add Demo ID '08' to claim. 15 = ESRD Managed Care (MCO encounter data) -- testing open enrollment of ESRD beneficiaries and capitation rates adjusted for patient treatment needs at 3 MCOs in 3 States. The claims contain one of the specific MCO Plan Contract # assigned to the ESRD demo site. NOTE: Effective 10/1/97 (but not actually imple- mented at a site until 1/1/98) for all claim types -- the FI and carrier add Demo ID '15' to claim based on the presence of the MCO plan contract #. 30 = Lung Volume Reduction Surgery (LVRS) or National Emphysema Treatment Trial (NETT) Clinical Study -- evaluating the effective- ness of LVRS and maximum medical therapy (in- cluding pulmonary rehab) for Medicare bene- ficiaries in last stages of emphysema at 18 hospitals nationally, in collaboration with NIH. NOTE: Effective for all claim types (except DMERC) with NCH weekly process date after 2/27/98 (and service date after 10/31/97) -- the FI adds Demo ID '30' based on the presence of a condition code = EY; the participating physician (not the carrier) adds ID to the noninstitutional claim. DUE TO THE SEN- SITIVE NATURE OF THIS CLINICAL TRIAL AND UNDER THE TERMS OF THE INTERAGENCY AGREEMENT WITH NIH, THESE CLAIMS ARE PROCESSED BY CWF AND TRANSMITTED TO HCFA BUT NOT STORED IN THE NEARLINE FILE (access is restricted to study evaluators only). 31 = VA Pricing Special Processing (SPN) -- not really a demo but special request from VA due to court settlement; not Medicare services but VA inpatient and physician services submitted to FI 00400 and Carrier 00900 to obtain Medicare pricing -- CWF WILL PROCESS VA CLAIMS ANNOTATED WITH DEMO ID '31', BUT WILL NOT TRANSMIT TO HCFA (not in Nearline File). 37 = Medicare Coordinated Care Demonstration -- to test whether coordinated care services furnished to certain beneficiaries improves outcome of care and reduces Medicare expenditures under Part A and Part B. There will be at least 14 Coordinated Care Entities (CCEs). The selected entities will be assigned a provider number specifically for the demonstration services. NOTE: All claims will be processed by carriers; no FI processing (except for Georgetown site) 37 = Medicare Disease Management (DMD) -- the purpose of this demonstration is to study the impact on costs and health outcomes of applying disease management services supplemented with coverage for prescription drugs for certain Medicare beneficiaries with diag- nosed, advanced-stage congestive heart failure, diabetes, or coronary heart disease. Three demon- stration sites will be used for this demonstration and it will last for 3 years. (Effective 4/1/2003). NOTE: All claims will be processed by NHIC-California (Carrier). FIs will only serve as a conduit for trans- mitting information to and from CWF about the NOEs. 38 = Physician Encounter Claims - the purpose of this demo id is to identify the physician encounter claims being processed at the HCFA Data Center (HDC). This number will help EDS in making the claim go through the appropriate processing logic, which differs from that for fee-for-service. **NOT IN NCH.** NOTE: Effective October, 2000. Demo ids will not be assigned to Inpatient and Outpatient encounter claims. 39 = Centralized Billing of Flu and PPV Claims -- The purpose of this demo is to facilitate the processing carrier, Trailblazers, paying flu and PPV claims based on payment localities. Providers will be giving the shots throughout the country and trans- mitting the claims to Trailblazers for processing. NOTE: Effective October, 2000 for carrier claims. 40 = Payment of Physician and Nonphysician Services in certain Indian Providers -- the purpose of this demo is to extend payment for services of physician and nonphysician practitioners furnished in hospitals and ambulatory care clinics. Prior to the legislation change in BIPA, reim- bursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and skilled nursing facilities. This change will allow payment for IHS, Tribe and Tribal Organization providers under the Medicare physician fee schedule. NOTE: Effective July 1, 2001 for institutional and carrier claims. 45 = Chiropractic 48 = Medical Adult Day-Care Services -- the purpose of this demonstration is to provide, as part of the episode of care for home health services, medical adult day care services to Medicare beneficiaries as a substitute for a portion of home health services that would otherwise be provided in the beneficiaries home. This demo would last approx. 3 years in not more than 5 sites. Payment for each home health ser- vice episode of care will be set at 95% of the amount that would otherwise be paid for home health services provided entirely in the home. NOTE: Effective July 5, 2005 for HHA claims. 49 = Hemodialysis 53 = Extended Stay 54 = ACE Demo 56 = ACA 3113 Lab Demo 58 = used to identify the Multi-payer Advanced Primary Care Practice (MAPCP) demonstration. (eff. 7/2/12 - CR7693/7283) 59 = ACO Pioneer Demonstration (CMS CR8140) - eff. 1/2014 60 = Power Motorized Device (PMD) 61 = CLM-CARE-IMPRVMT-MODEL-1 62 = CLM-CARE-IMPRVMT-MODEL-2 63 = CLM-CARE-IMPRVMT-MODEL-3 64 = CLM-CARE-IMPRVMT-MODEL-4 65 = rebilled claims due to auditor denials -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full because of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12 -- CR7738) 66 = rebilled claims due to provider self-audit after claim submission/payment -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full be- cause of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12 -- CR7738) 67 = rebilled claims due to provider self-audit after the patient has been discharged,but prior to payment -- code being implemented for a demonstration to determine the efficiency of allowing providers to rebill for all outpatient services, minus a penalty, when an inpatient claim is denied in full because of medical review because the beneficiary did not require inpatient services. (eff. 7/2/12 -- CR7738) 68 = CWF will not apply the 3-day hospital stay requirement when processing a SNF claim. (CMS CR8215) - eff. 1/2014 70 = used for Electrical Workers Insurance Fund claims. (eff. 7/2/12) 71 = Intravenous Immune Globin (IVIG) 75 = Comprehensive Care for Joint Replacement (CCJR) (eff. 4/2016) 77 = Shared Savings Program (eff. 10/2016) 78 = Comprehensive Primary Care Plus (CPC+) (eff. 4/2017) 79 = Acute Myocardial Infarction (AMI) Episode Payment Model (EPM) ( (eff. 1/2018) 80 = Coronary Artery Bypass Graft (CABG) Episode Payment Model (EPM) (eff. 1/2018) 81 = Surgical Hip and Femur Fracture Treatment (SHFFT) Episode Payment Model (EMP) (eff. 1/2018) 82 = Medicare Diabetes Prevention Program (MDPPs) (eff. 4/2018) 83 = Maryland Primary Care Program (MDPCP) (eff. 1/2018) 86 = Bundled Payments for Care Improvement Advanced Model 87 = Prospective Bundled Payments for Radiation Oncology (RO) Model (eff. 1/2020) 91 = Emergency Triage, Treat, and Transport (ET3) Model - is a voluntary, 5-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare FFS beneficiaries following a 911 call. (eff. 1/2020) 92 = Direct Contracting (DC) Model - Professional and Global Options: Total Care Capitation (TCC), Primary Care Capitation (PCC), Advanced Payment Option (APO), Telehealth Expansion, 3-day SNF Rule Waiver, Post-Discharge and Care-Management Home Visits - The Direct Contracting (DC) Model creates a new opportunity for CMS to test an array of financial risk- sharing arrangements, leveraging lessons learned from other Medicare ACO initiatives. As an ACO-like Model, DC allows participating organizations to take on the financial risk for Medicare Part A and B expenditures for a defined popula- tion of fee-for-service Medicare beneficiaries over a defined period of time (5 years, separated into 1-year increments called Performance Years (PYs)). eff. 4/2021 94 = ESRD Treatment Choices (ETC) - eff. 1/2020 - Outpatient and Carrier Only (eff. 1/2020) 95 = Oncology Care Model Plus (OCM+) - eff. 1/2020 96 = New Primary Care First (PCF) model - has two separate but related components: (1) the PCF component and (2) the Seriously Ill Population (SIP) component. Both components will test alternative payments and the provision of technical support to primary care prac- tices. These PCF and/or SIP participants will receive a combination of claims and non-claims-based payments based on their attributed Medicare fee-for-service (FFS) beneficiaries. Every participating practice will be given a unique practice ID by the CMS implementation support contractor. Providers in a practice will be uniquely defined by the combination of each provider's tax ID number (TIN) and national provider identifier (NPI). Eff. 1/2021 97 = Kidney Care Choices (KCC) Kidney Care First (KCF) - For the CMS Kidney Care First (KCF) Option, nephrologists and and nephrology practices will receive adjusted capitated payments for managing beneficiaries with Chronic Kidney Disease (CKD) stages 4 and stages 5 and ESRD (End State Renal Disease), and will be eligible for upward or downward payment adjustments based on the quality of their performance and improvements in their performance over time. This model is designed to emulate the basic design of the Primary Care First (PCF) Model. eff. 4/2021. 98 = Pennsylvania Rural Health Model (PARHM) - The provides provides rural acute care hospitals and Critical Access Hospitals (CAH) the opportunity to participate in hospital global budget payments for all inpatient and outpatient hospital services and CAH swing bed services. CMS reimburses participant rural hospitals according to an annual global budget, which is provided by the Commonwealth of Pennsylvania. Participant rural hospitals also submit claims to CMS, but zero claims payments are made. Eff. 1/2018 99 = Opiod Use Disorder (OUD) Treatment Model - is a 4-year The purpose of Value in OUD Treatment is to "increase access of applicable beneficiaries to opioid use disorder treatment services, improve physical and mental health outcomes for such beneficiaries, and to the extent possible, reduce Medicare program expenditures." Eff. 4/2021 DB2 ALIAS : CLM_DEMO_ID_NUM SAS ALIAS : DEMONUM STANDARD ALIAS : CLM_DEMO_ID_NUM TITLE ALIAS : DEMO_ID LENGTH : 2 SOURCE : CWF 118. Claim Demonstration Information Text 15 1531 1545 CHAR Effective with Version H, the text field that contains related demo information. For example, a claim involving a CHOICES demo id '05' would contain the MCO plan contract number in the first five positions of this text field. NOTE: During the Version H conversion this field was populated with data throughout history. DB2 ALIAS : CLM_DEMO_INFO_TXT SAS ALIAS : DEMOTXT STANDARD ALIAS : CLM_DEMO_INFO_TXT TITLE ALIAS : DEMO_INFO LENGTH : 15 DERIVATIONS : DERIVATION RULES: Demo ID = 01 (RUGS) -- the text field will contain a 2, 3 or 4 to denote the RUGS phase. If RUGS phase is blank or not one of the above the text field will reflect 'INVALID'. NOTE: In Version 'G', RUGS phase was stored in redefined Claim Edit Group, 3rd occurrence, 4th position. Demo ID = 02 (Home Health demo) -- the text field will contain PROV#. When demo number not equal to 02 then text will reflect 'INVALID'. Demo ID = 03 (Telemedicine demo) -- text field will contain the HCPCS code. If the required HCPCS is not shown then the text field will reflect 'INVALID'. Demo ID = 04 (UMWA) -- text field will contain W0 denoting that condition code W0 was present. If condition code W0 not present then the text field will reflect 'INVALID'. Demo ID = 05 (CHOICES) -- the text field will con- tain the CHOICES plan number, if both of the follow- ing conditions are met: (1) CHOICES plan number present and PPS or Inpatient claim shows that 1st 3 positions of provider number as '210' and the admission date is within HMO effective/termination date; or non-PPS claim and the from date is within HMO effective/termination date and (2) CHOICES plan number matches the HMO plan number. If either condition is not met the text field will reflect 'INVALID CHOICES PLAN NUMBER'. When CHOICES plan number not present, text will re- flect 'INVALID'. NOTE: In Version 'G', a valid CHOICES plan ID is stored as alpha character in redefined Claim Edit Group, 4th occurrence, 2nd position. If invalid, CHOICES indicator 'ZZ' displayed. Demo ID = 15 (ESRD Managed Care) -- text field will contain the ESRD/MCO plan number. If ESRD/ MCO plan number not present the field will reflect 'INVALID'. Demo ID = 38 (Physician Encounter Claims) -- text field will contain the MCO plan number. When MCO plan number not present the field will reflect 'INVALID'. SOURCE : CWF LIMITATIONS : REFER TO : CHOICES_DEMO_LIM 119. Carrier Claim Diagnosis Group 108 1618 1725 GRP The number of claim diagnosis trailers is determined by the carrier claim diagnosis code count. STANDARD ALIAS : CARR_CLM_DGNS_GRP OCCURS MIN: 0 OCCURS MAX: 12 DEPENDING ON : DMERC_CLM_DGNS_CD_J_CNT 120. NCH Diagnosis Trailer Indicator Code 1 1618 1618 CHAR Effective with Version H, the code indicating the presence of a diagnosis trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS : DGNS_TRLR_IND_CD SAS ALIAS : DGNSIND STANDARD ALIAS : NCH_DGNS_TRLR_IND_CD LENGTH : 1 SOURCE : NCH CODE TABLE : NCH_DGNS_TRLR_IND_TB 121. Claim Diagnosis Version Code 1 1619 1619 CHAR Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10. NOTE: With 5010, the diagnosis and procedure codes have been expanded to accommodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2014. DB2 ALIAS : CLM_DGNS_VRSN_CD SAS ALIAS : DVRSNCD STANDARD ALIAS : CLM_DGNS_VRSN_CD LENGTH : 1 CODE TABLE : CLM_DGNS_VRSN_TB 122. Claim Diagnosis Code 7 1620 1626 CHAR The diagnosis code identifying the beneficiary's principal or other diagnosis (including E code). NOTE: Prior to Version H, the principal diagnosis code was not stored with the 'OTHER' diagnosis codes. During the Version H conversion the CLM_PRNCPAL_DGNS_CD was added as the first occurrence. NOTE1: Effective with Version 'J', this field has been expanded from 5 bytes to 7 bytes to accommodate the future implementation of ICD-10. NOTE2: Effective with Version 'J', the diagnosis E codes are stored in a separate trailer (CLM_DGNS_E_GRP). DB2 ALIAS : CLM_DGNS_CD SAS ALIAS : DGNS_CD STANDARD ALIAS : CLM_DGNS_CD LENGTH : 7 EDIT RULES : ICD-9-CM 123. DMERC Line Group 17199 1726 18924 GRP OCCURS MIN: 0 OCCURS MAX: 13 DEPENDING ON : DMERC_CLM_LINE_CNT 124. NCH Line Item Trailer Indicator Code 1 1726 1726 CHAR Effective with Version H, the code indicating the presence of a line item trailer on the non- institutional claim. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS : LINE_TRLR_IND_CD SAS ALIAS : LINEIND STANDARD ALIAS : NCH_LINE_TRLR_IND_CD LENGTH : 1 SOURCE : NCH CODE TABLE : NCH_LINE_TRLR_IND_TB 125. DMERC Line Supplier Provider Number 10 1727 1736 CHAR Effective with Version 'G', billing number assigned tothe supplier of the Part B service/DMEPOS by the National Supplier Clearinghouse, as reported on the line item for the DMERC claim. DB2 ALIAS : SUPLR_PRVDR_NUM SAS ALIAS : SUPLRNUM STANDARD ALIAS : DMERC_LINE_SUPLR_PRVDR_NUM TITLE ALIAS : SUPLR_NUM LENGTH : 10 COMMENTS : Prior to Version H this field was named: CWFB_SUPLR_PRVDR_NUM. SOURCE : CWF 126. DMERC Line Item Supplier NPI Number 10 1737 1746 CHAR The National Provider Identifier (NPI) assigned to the supplier of the Part B service/DMEPOS line item. NOTE: Effective May 2007, the NPI will become the national standard identifier for covered health care providers. NPIs will replace the current legacy provider numbers (UPINs, PINs, OSCAR provider numbers, etc.) on the standard HIPPA claim transactions. (During the NPI transition phase (4/3/06 - 5/23/07) the capa- bility was there for the NCH to receive NPIs along with an existing legacy number (UPIN, NPIs OSCAR provider numbers, etc.). NOTE1: CMS has determined that dual provider identifiers (legacy numbers and NPIs) must be available on the NCH. After the 5/07 NPI implementation, the standard system maintainers will add the legacy number to the claim when it is adjudicated. Effective May 2007, no NEW UPINs will be generated for NEW physicians (Part B and Outpatient claims) so there will only be NPIs sent in to the NCH for those phy- sicians. COMMON ALIAS : SUPPLIER_NPI DB2 ALIAS : SUPLR_NPI_NUM SAS ALIAS : SUP_NPI STANDARD ALIAS : DMERC_LINE_SUPLR_NPI_NUM TITLE ALIAS : SUPLR_NPI LENGTH : 10 SOURCE : CWF 127. DMERC Line Pricing State Code 2 1747 1748 CHAR Prior to Version H this field was named: CWFB_DME_PRCNG_STATE_CD. DB2 ALIAS : DMERC_PRCNG_STATE SAS ALIAS : PRCNG_ST STANDARD ALIAS : DMERC_LINE_PRCNG_STATE_CD TITLE ALIAS : DMERC_PRCNG_STATE_CD LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_DME_PRCNG_STATE_CD. SOURCE : CWF/NCH CODE TABLE : GEO_SSA_STATE_TB 128. DMERC Line Pricing Zip Code 9 1749 1757 CHAR The zip code used to identify where the supply/item was rendered. The pricing state code and the pricing zip code will be used in pricing DMEPOS claims. NOTE: Due to a change in the CWF release schedule, we will not see data in this field until April 2010. DB2 ALIAS : DMERC_PRCNG_ZIP_CD SAS ALIAS : PRCNGZIP STANDARD ALIAS : DMERC_LINE_PRCNG_ZIP_CD LENGTH : 9 LANGUAGE : C 129. DMERC Line Beneficiary Mailing State Code 2 1758 1759 CHAR The state code used to identify the beneficiary's mailing address. This state code may be the same as the pricing state code, but it could be different(e.g. representative payee, temporary address, etc.). NOTE1: The pricing state code (existing field) will contain the state code where the supply/item was rendered. The mailing state code (new field) will represent where the beneficiary's MSN is sent. NOTE2: NOTE: Due to a change in the CWF release schedule, we will not see data in this field until April 2010. DB2 ALIAS : DMERC_MLG_STATE_CD SAS ALIAS : MLGSTATE STANDARD ALIAS : DMERC_LINE_BENE_MLG_STATE_CD LENGTH : 2 LANGUAGE : C 130. DMERC Line Provider State Code 2 1760 1761 CHAR Prior to Version H this field was named: CWFB_DME_PRVDR_STATE_CD. DB2 ALIAS : DMERC_PRVDR_STATE SAS ALIAS : PRVSTATE STANDARD ALIAS : DMERC_LINE_PRVDR_STATE_CD TITLE ALIAS : DMERC_PRVDR_STATE_CD LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_DME_PRVDR_STATE_CD. SOURCE : CWF/NCH CODE TABLE : GEO_SSA_STATE_TB 131. DMERC Line Supplier Type Code 1 1762 1762 CHAR Prior to Version H this field on the DMERC claim was named: CWFB_PRVDR_TYPE_CD. DB2 ALIAS : SUPLR_TYPE_CD SAS ALIAS : SUP_TYPE STANDARD ALIAS : DMERC_LINE_SUPLR_TYPE_CD TITLE ALIAS : SUPLR_TYPE LENGTH : 1 COMMENTS : Prior to Version H this field on the DMERC claim was named: CWFB_PRVDR_TYPE_CD. SOURCE : CWF CODE TABLE : DMERC_LINE_SUPLR_TYPE_TB 132. Line Provider Tax Number 10 1763 1772 CHAR Social security number or employee identification number of physician/supplier used to identify to whom payment is made for the line item service on the noninstitutional claim. Note: The first 9 positions contain the Social Security/Tax Number and the 10th position contains the provider type code. DB2 ALIAS : LINE_PRVDR_TAX_NUM SAS ALIAS : TAX_NUM STANDARD ALIAS : LINE_PRVDR_TAX_NUM TITLE ALIAS : PRVDR_TAX_NUM LENGTH : 10 COMMENTS : Prior to Version H this field was named: CWFB_PRVDR_TAX_NUM. SOURCE : NCH 133. Line HCFA Provider Specialty Code 2 1773 1774 CHAR CMS specialty code used for pricing the line item service on the noninstitutional claim. DB2 ALIAS : HCFA_SPCLTY_CD SAS ALIAS : HCFASPCL STANDARD ALIAS : LINE_HCFA_PRVDR_SPCLTY_CD TITLE ALIAS : HCFA_PRVDR_SPCLTY LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_HCFA_PRVDR_SPCLTY_CD. SOURCE : CWF CODE TABLE : CMS_PRVDR_SPCLTY_TB 134. Line Provider Participating Indicator Code 1 1775 1775 CHAR Code indicating whether or not a provider is participating or accepting assignment for this line item service on the noninstitutional claim. DB2 ALIAS : PRVDR_PRTCPTG_CD SAS ALIAS : PRTCPTG STANDARD ALIAS : LINE_PRVDR_PRTCPTG_IND_CD TITLE ALIAS : PRVDR_PRTCPTG_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_PRVDR_PRTCPTG_IND_CD. SOURCE : CWF CODE TABLE : LINE_PRVDR_PRTCPTG_IND_TB 135. Line Service Count 6 1776 1781 PACK The count of the total number of services processed for the line item on the non-institutional claim. DB2 ALIAS : SRVC_CNT SAS ALIAS : SRVC_CNT STANDARD ALIAS : LINE_SRVC_CNT LENGTH : 7.3 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_SRVC_CNT. Prior to Version 'J', this field was S9(3) Length: 7.3 SOURCE : CWF 136. Line HCFA Type Service Code 1 1782 1782 CHAR Code indicating the type of service, as defined in the CMS Medicare Carrier Manual, for this line item on the non-institutional claim. DB2 ALIAS : HCFA_TYPE_SRVC_CD SAS ALIAS : TYPSRVCB STANDARD ALIAS : LINE_HCFA_TYPE_SRVC_CD TITLE ALIAS : HCFA_TYPE_SRVC LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_HCFA_TYPE_SRVC_CD. SOURCE : CWF EDIT RULES : The only type of service codes applicable to DMERC claims are: 1, 9, A, E, G, H, J, K, L, M, P, R, and S. CODE TABLE : CMS_TYPE_SRVC_TB 137. Line Place of Service Code 2 1783 1784 CHAR The code indicating the place of service, as defined in the Medicare Carrier Manual, for this line item on the noninstitutional claim. COMMON ALIAS : POS DB2 ALIAS : LINE_PLC_SRVC_CD SAS ALIAS : PLCSRVC STANDARD ALIAS : LINE_PLC_SRVC_CD TITLE ALIAS : PLC_SRVC LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_PLC_SRVC_CD. SOURCE : CWF CODE TABLE : LINE_PLC_SRVC_TB 138. Line First Expense Date 8 1785 1792 NUM Beginning date (1st expense) for this line item service on the noninstitutional claim. DB2 ALIAS : LINE_1ST_EXPNS_DT SAS ALIAS : EXPNSDT1 STANDARD ALIAS : LINE_1ST_EXPNS_DT TITLE ALIAS : 1ST_EXPNS_DT LENGTH : 8 SIGNED : N COMMENTS : Prior to Version H this field was named: CWFB_1ST_EXPNS_DT. SOURCE : CWF EDIT RULES : YYYYMMDD 139. Line Last Expense Date 8 1793 1800 NUM The ending date (last expense) for the line item service on the noninstitutional claim. DB2 ALIAS : LINE_LAST_EXPNS_DT SAS ALIAS : EXPNSDT2 STANDARD ALIAS : LINE_LAST_EXPNS_DT TITLE ALIAS : LAST_EXPNS_DT LENGTH : 8 SIGNED : N COMMENTS : Prior to Version H this field was named: CWFB_LAST_EXPNS_DT. SOURCE : CWF EDIT RULES : YYYYMMDD 140. Line HCPCS Code 5 1801 1805 CHAR The Health Care Common Procedure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs. The codes are divided into three levels, or groups as described below: DB2 ALIAS : LINE_HCPCS_CD SAS ALIAS : HCPCS_CD STANDARD ALIAS : LINE_HCPCS_CD TITLE ALIAS : HCPCS_CD LENGTH : 5 COMMENTS : Prior to Version H this line item field was named: HCPCS_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and noninstitutional: LINE). Level I Codes and descriptors copyrighted by the American Medical Association's Current Procedural Terminology, Fourth Edition (CPT-4). These are 5 position numeric codes representing physician and nonphysician services. **** Note: **** CPT-4 codes including both long and short descriptions shall be used in accordance with the CMS/AMA agreement. Any other use violates the AMA copyright. Level II Includes codes and descriptors copyrighted by the American Dental Association's Current Dental Terminology, Fifth Edition (CDT-5). These are 5 position alpha-numeric codes comprising the D series. All other level II codes and descriptors are approved and maintained jointly by the alpha-numeric editorial panel (consisting of CMS, the Health Insurance Association of America, and the Blue Cross and Blue Shield Association). These are 5 position alpha- numeric codes representing primarily items and nonphysician services that are not represented in the level I codes. Level III Codes and descriptors developed by Medicare carriers for use at the local (carrier) level. These are 5 position alpha-numeric codes in the W, X, Y or Z series representing physician and nonphysician services that are not represented in the level I or level II codes. 141. Line HCPCS Initial Modifier Code 2 1806 1807 CHAR A first modifier to the HCPCS procedure code to enable a more specific procedure identification for the line item service on the noninstitutional claim. DB2 ALIAS : UNDEFINED SAS ALIAS : MDFR_CD1 STANDARD ALIAS : LINE_HCPCS_INITL_MDFR_CD TITLE ALIAS : INITIAL_MODIFIER LENGTH : 2 COMMENTS : Prior to Version H this field was named: HCPCS_INITL_MDFR_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and noninstitutional: LINE). SOURCE : CWF EDIT RULES : CARRIER INFORMATION FILE 142. Line HCPCS Second Modifier Code 2 1808 1809 CHAR A second modifier to the HCPCS procedure code to make it more specific than the first modifier code to identify the line item procedures for this claim. DB2 ALIAS : UNDEFINED SAS ALIAS : MDFR_CD2 STANDARD ALIAS : LINE_HCPCS_2ND_MDFR_CD TITLE ALIAS : SECOND_MODIFIER LENGTH : 2 COMMENTS : Prior to Version H this field was named: HCPCS_2ND_MDFR_CD. With Version H, a prefix was added to denote the location of this field on each claim type (institutional: REV_CNTR and noninstitutional: LINE). SOURCE : CWF EDIT RULES : CARRIER INFORMATION FILE 143. DMERC Line HCPCS Third Modifier Code 2 1810 1811 CHAR Prior to Version H this field was named: HCPCS_3RD_MDFR_CD. DB2 ALIAS : HCPCS_3RD_MDFR_CD SAS ALIAS : MDFR_CD3 STANDARD ALIAS : DMERC_LINE_HCPCS_3RD_MDFR_CD TITLE ALIAS : HCPCS_3RD_MDFR LENGTH : 2 COMMENTS : Prior to Version H this field was named: HCPCS_3RD_MDFR_CD. SOURCE : CWF 144. DMERC Line HCPCS Fourth Modifier Code 2 1812 1813 CHAR Prior to Version H this field was named: HCPCS_4TH_MDFR_CD. DB2 ALIAS : HCPCS_4TH_MDFR_CD SAS ALIAS : MDFR_CD4 STANDARD ALIAS : DMERC_LINE_HCPCS_4TH_MDFR_CD TITLE ALIAS : HCPCS_4TH_MDFR LENGTH : 2 COMMENTS : Prior to Version H this field was named: HCPCS_4TH_MDFR_CD. SOURCE : CWF 145. Line NCH BETOS Code 3 1814 1816 CHAR Effective with Version H, the Berenson-Eggers type of service (BETOS) for the procedure code based on generally agreed upon clinically meaningful groupings of procedures and services. This field is included as a line item on the noninstitutional claim. NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991). DB2 ALIAS : LINE_NCH_BETOS_CD SAS ALIAS : BETOS STANDARD ALIAS : LINE_NCH_BETOS_CD TITLE ALIAS : BETOS LENGTH : 3 DERIVATIONS : DERIVED FROM: LINE_HCPCS_CD LINE_HCPCS_INITL_MDFR_CD LINE_HCPCS_2ND_MDFR_CD HCPCS MASTER FILE DERIVATION RULES: Match the HCPCS on the claim to the HCPCS on the HCPCS Master File to obtain the BETOS code. SOURCE : NCH CODE TABLE : BETOS_TB 146. Line IDE Number 7 1817 1823 CHAR Effective with Version H, the exemption number assigned by the Food and Drug Administration (FDA) to an investigational device after a manufacturer has been approved by FDA to conduct a clinical trial on that device. HCFA established a new policy of covering certain IDE's which was implemented in claims processing on 10/1/96 (which is NCH weekly process 10/4/96) for service dates beginning 10/1/95. NOTE: Prior to Version H a dummy line item was created in the last occurrence of line item group to store IDE. The IDE number was housed in two fields: HCPCS code and HCPCS initial modifier; the second modifier contained the value 'ID'. There will be only one distinct IDE number reported on the non-institutional claim. During the Version H conversion, the IDE was moved from the dummy line item to its own dedicated field for each line item (i.e., the IDE was repeated on all line items on the claim.) DB2 ALIAS : LINE_IDE_NUM SAS ALIAS : LINE_IDE STANDARD ALIAS : LINE_IDE_NUM TITLE ALIAS : IDE_NUMBER LENGTH : 7 SOURCE : CWF 147. DMERC Line Not Otherwise Classified HCPCS Code Text 14 1824 1837 CHAR Prior to Version H this field was named: CWFB_DME_ITM_NOC_HCPCS_CD_TXT. DB2 ALIAS : NOC_HCPCS_CD_TXT SAS ALIAS : NOC_TXT STANDARD ALIAS : DMERC_LINE_NOC_HCPCS_CD_TXT TITLE ALIAS : NOC_HCPCS_TXT LENGTH : 14 COMMENTS : Prior to Version H this field was named: CWFB_DME_ITM_NOC_HCPCS_CD_TXT. SOURCE : CWF 148. Line National Drug Code 11 1838 1848 CHAR Effective 1/1/94 on the DMERC claim, the National Drug Code identifying the oral anti-cancer drugs. Effective with Version H, this line item field was added as a placeholder on the carrier claim. DB2 ALIAS : LINE_NATL_DRUG_CD SAS ALIAS : NDC_CD STANDARD ALIAS : LINE_NATL_DRUG_CD TITLE ALIAS : NDC_CD LENGTH : 11 SOURCE : CWF 149. Line NCH Payment Amount 6 1849 1854 PACK Amount of payment made from the trust funds (after deductible and coinsurance amounts have been paid) for the line item service on the non- institutional claim. COMMON ALIAS : REIMBURSEMENT DB2 ALIAS : LINE_NCH_PMT_AMT SAS ALIAS : LINEPMT STANDARD ALIAS : LINE_NCH_PMT_AMT TITLE ALIAS : REIMBURSEMENT LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this line item field was named: CLM_PMT_AMT and the size of this field was S9(7)V99. SOURCE : NCH EDIT RULES : $$$$$$$$$CC 150. Line Beneficiary Payment Amount 6 1855 1860 PACK Effective with Version H, the payment (reim- bursement) made to the beneficiary related to the line item service on the noninstitu- tional claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : LINE_BENE_PMT_AMT SAS ALIAS : LBENPMT STANDARD ALIAS : LINE_BENE_PMT_AMT TITLE ALIAS : BENE_PMT_AMT LENGTH : 9.2 SIGNED : Y SOURCE : CWF 151. Line Provider Payment Amount 6 1861 1866 PACK Effective with Version H, the payment made to the provider for the line item service on the noninstitutional claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : LINE_PRVDR_PMT_AMT SAS ALIAS : LPRVPMT STANDARD ALIAS : LINE_PRVDR_PMT_AMT TITLE ALIAS : PRVDR_PMT_AMT LENGTH : 9.2 SIGNED : Y SOURCE : CWF 152. Line Beneficiary Part B Deductible Amount 6 1867 1872 PACK The amount of money for which the carrier has determined that the beneficiary is liable for the Part B cash deductible for the line item service on the noninstitutional claim. DB2 ALIAS : LINE_DDCTBL_AMT SAS ALIAS : LDEDAMT STANDARD ALIAS : LINE_BENE_PTB_DDCTBL_AMT TITLE ALIAS : PTB_DED_AMT LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: BENE_PTB_DDCTBL_LBLTY_AMT and the size of the field was S9(3)V99. SOURCE : CWF EDIT RULES : $$$$$$$$$CC 153. Line Beneficiary Primary Payer Code 1 1873 1873 CHAR The code specifying a federal non-Medicare program or other source that has primary responsibility for the payment of the Medicare beneficiary's medical bills relating to the line item service on the noninstitutional claim. DB2 ALIAS : LINE_PRMRY_PYR_CD SAS ALIAS : LPRPAYCD STANDARD ALIAS : LINE_BENE_PRMRY_PYR_CD TITLE ALIAS : PRIMARY_PAYER_CD LENGTH : 1 COMMENTS : Prior to Version H this field was named: BENE_PRMRY_PYR_CD. SOURCE : CWF,VA,DOL,SSA CODE TABLE : BENE_PRMRY_PYR_TB 154. Line Beneficiary Primary Payer Paid Amount 6 1874 1879 PACK The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than Medicare, that the provider is applying to covered Medicare charges for to the line ITEM SERVICE ON THE NONINSTITUTIONAL. DB2 ALIAS : LINE_PRMRY_PYR_PD SAS ALIAS : LPRPDAMT STANDARD ALIAS : LINE_BENE_PRMRY_PYR_PD_AMT TITLE ALIAS : PRMRY_PYR_PD LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: BENE_PRMRY_PYR_PMY_AMT and the field size was S9(5)V99. SOURCE : CWF EDIT RULES : $$$$$$$$$CC 155. Line Coinsurance Amount 6 1880 1885 PACK Effective with Version H, the beneficiary coinsurance liability amount for this line item service on the noninstitutional claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : LINE_COINSRNC_AMT SAS ALIAS : COINAMT STANDARD ALIAS : LINE_COINSRNC_AMT TITLE ALIAS : COINSRNC_AMT LENGTH : 9.2 SIGNED : Y SOURCE : CWF 156. Line Interest Amount 6 1886 1891 PACK Amount of interest to be paid for this line item service on the noninstitutional claim. **NOTE: This is not included in the line item NCH payment (reimbursement) amount. DB2 ALIAS : LINE_INTRST_AMT SAS ALIAS : LINT_AMT STANDARD ALIAS : LINE_INTRST_AMT TITLE ALIAS : INTRST_AMT LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_INTRST_AMT and the field size was S9(5)V99. SOURCE : CWF EDIT RULES : $$$$$$$$$CC 157. Line Primary Payer Allowed Charge Amount 6 1892 1897 PACK Effective with Version H, the primary payer allowed charge amount for the line item service on the noninstitutional claim. NOTE: Beginning with NCH weekly process date 10/3/97 this field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. DB2 ALIAS : PRMRY_PYR_ALOW_AMT SAS ALIAS : PRPYALOW STANDARD ALIAS : LINE_PRMRY_PYR_ALOW_CHRG_AMT TITLE ALIAS : PRMRY_PYR_ALOW_CHRG LENGTH : 9.2 SIGNED : Y SOURCE : CWF 158. Line 10% Penalty Reduction Amount 6 1898 1903 PACK Effective with Version H, the 10% payment reduction amount (applicable to a late filing claim) for the line item service. on the noninstitutional claim. DB2 ALIAS : TENPCT_PNLTY_AMT SAS ALIAS : PNLTYAMT STANDARD ALIAS : LINE_10PCT_PNLTY_RDCTN_AMT TITLE ALIAS : TENPCT_PNLTY LENGTH : 9.2 SIGNED : Y SOURCE : CWF 159. Line Submitted Charge Amount 6 1904 1909 PACK The amount of submitted charges for the line item service on the noninstitutional claim. DB2 ALIAS : LINE_SBMT_CHRG_AMT SAS ALIAS : LSBMTCHG STANDARD ALIAS : LINE_SBMT_CHRG_AMT TITLE ALIAS : SBMT_CHRG LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_SBMT_CHRG_AMT and the field size was S9(5)V99. SOURCE : CWF EDIT RULES : $$$$$$$$$CC 160. Line Allowed Charge Amount 6 1910 1915 PACK The amount of allowed charges for the line item service on the noninstitutional claim. This charge is used to compute pay to providers or reimbursement to beneficiaries. **NOTE: The Note1: The amount includes beneficiary-paid amounts (i.e., deductible and coinsurance). Note2: The allowed charge is determined by the lower of three charges: prevailing, customary or actual. DB2 ALIAS : LINE_ALOW_CHRG_AMT SAS ALIAS : LALOWCHG STANDARD ALIAS : LINE_ALOW_CHRG_AMT TITLE ALIAS : ALOW_CHRG LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_ALOW_CHRG_AMT and the field size was S9(5)V99. SOURCE : CWF EDIT RULES : $$$$$$$CC 161. DMERC Line Screen Savings Amount 6 1916 1921 PACK Prior to Version H this field was named: CWFB_DME_SCRN_SVGS_AMT and the field size was S9(5)V99. DB2 ALIAS : LINE_SCRN_SVGS_AMT SAS ALIAS : SCRNSVGS STANDARD ALIAS : DMERC_LINE_SCRN_SVGS_AMT TITLE ALIAS : SCRN_SVGS LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_DME_SCRN_SVGS_AMT and the field size was S9(5)V99. SOURCE : CWF 162. Line DME Purchase Price Amount 6 1922 1927 PACK Effective 5/92, the amount representing the lower of fee schedule for purchase of new or used DME, or actual charge. In case of rental DME, this amount represents the purchase cap; rental payments can only be made until the cap is met. This line item field is applicable to non-institutional claims involving DME, prosthetic, orthotic and supply items, immunosuppressive drugs, pen, ESRD and oxygen items referred to as DMEPOS. DB2 ALIAS : DME_PURC_PRICE_AMT SAS ALIAS : DME_PURC STANDARD ALIAS : LINE_DME_PURC_PRICE_AMT TITLE ALIAS : DME_PURC_PRICE LENGTH : 9.2 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_DME_PURC_PRICE_AMT and the field size was S9(5)V99. SOURCE : CWF EDIT RULES : $$$$$$$$$CC 163. Line Processing Indicator Code 2 1928 1929 CHAR The code on a noninstitutional claim indicating to whom payment was made or if the claim was denied. NOTE1: Effective 4/1/02, this field was expanded to two bytes to accommodate new values. The NCH Nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of code for the crosswalk. NOTE2: Effective with Version 'J', the field has been expanded on the NCH record to 2 bytes, With this expansion, the NCH will no longer use the character values to represent the official two byte values sent in by CWF since 4/2002. During the Version J conversion, all character values were converted to the two byte values. DB2 ALIAS : LINE_PRCSG_IND_CD SAS ALIAS : PRCNGIND STANDARD ALIAS : LINE_PRCSG_IND_CD LENGTH : 2 COMMENTS : Prior to Version H this field was named: CWFB_PRCSG_IND_CD. SOURCE : CWF CODE TABLE : LINE_PRCSG_IND_TB 164. Line Payment 80%/100% Code 1 1930 1930 CHAR The code indicating that the amount shown in the payment field on the noninstitutional line item represents either 80% or 100% of the allowed charges less any deductible, or 100% limitation of liability only. COMMON ALIAS : REIMBURSEMENT_IND DB2 ALIAS : LINE_PMT_80_100_CD SAS ALIAS : PMTINDSW STANDARD ALIAS : LINE_PMT_80_100_CD TITLE ALIAS : REINBURSEMENT_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_PMT_80_100_CD. SOURCE : CWF CODE TABLE : LINE_PMT_80_100_TB 165. Line Service Deductible Indicator Switch 1 1931 1931 CHAR Switch indicating whether or not the line item service on the noninstitutional claim is subject to a deductible. DB2 ALIAS : SRVC_DDCTBL_SW SAS ALIAS : DED_SW STANDARD ALIAS : LINE_SRVC_DDCTBL_IND_SW TITLE ALIAS : SRVC_DED_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_SRVC_DDCTBL_IND_SW. SOURCE : CWF CODE TABLE : LINE_SRVC_DDCTBL_IND_TB 166. Line Payment Indicator Code 1 1932 1932 CHAR Code that indicates the payment screen used to determine the allowed charge for the line item service on the noninstitutional claim. DB2 ALIAS : LINE_PMT_IND_CD SAS ALIAS : PMTINDCD STANDARD ALIAS : LINE_PMT_IND_CD TITLE ALIAS : PMT_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_PMT_IND_CD. SOURCE : CWF 167. DMERC Line Miles/Time/Units/Services Count 6 1933 1938 PACK The count of the total units associated with the DMERC line item service needing unit reporting, including number of services, volume of oxygen and drug dose. DB2 ALIAS : DMERC_MTUS_CNT SAS ALIAS : DME_UNIT STANDARD ALIAS : DMERC_LINE_MTUS_CNT TITLE ALIAS : MTUS_CNT LENGTH : 7.3 SIGNED : Y COMMENTS : Prior to Version H this field was named: CWFB_MTUS_CNT. Prior to Version 'J', this field was S9(3) Length: 7.3 168. DMERC Line Miles/Time/Units/Services Indicator Code 1 1939 1939 CHAR Prior to Version H this field was named: CWFB_DME_MTUS_IND_CD. DB2 ALIAS : DMERC_MTUS_IND_CD SAS ALIAS : UNIT_IND STANDARD ALIAS : DMERC_LINE_MTUS_IND_CD TITLE ALIAS : MTUS_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_DME_MTUS_IND_CD. SOURCE : CWF CODE TABLE : DMERC_LINE_MTUS_IND_TB 169. Line Diagnosis Code Group 8 1940 1947 GRP Effective with Version 'J', the group used to identify the diagnosis codes at the line level. This group contains the diagnosis code and the diagnosis version code. STANDARD ALIAS : LINE_DGNS_CD_GRP 170. Line Diagnosis Version Code 1 1940 1940 CHAR Effective with Version 'J', the code used to indicate if the diagnosis code is ICD-9 or ICD-10. NOTE: With 5010, the diagnosis and procedure codes have been expanded to accomodate ICD-10, even though ICD-10 is not scheduled for implementation until 10/2013. DB2 ALIAS : UNDEFINED SAS ALIAS : LDVRSNCD STANDARD ALIAS : LINE_DGNS_VRSN_CD LENGTH : 1 CODE TABLE : LINE_DGNS_VRSN_TB 171. Line Diagnosis Code 7 1941 1947 CHAR The code indicating the diagnosis supporting this line item procedure/service on the noninstitutional claim. DB2 ALIAS : LINE_DGNS_CD SAS ALIAS : LINEDGNS STANDARD ALIAS : LINE_DGNS_CD TITLE ALIAS : DGNS_CD LENGTH : 7 COMMENTS : Prior to Version H this field was named: CWFB_LINE_DGNS_CD. SOURCE : CWF 172. Line Additional Claim Documentation Indicator Code 1 1948 1948 CHAR Effective 5/92, the code indicating additional claim documentation was submitted for this line item service on the noninstitutional claim. COMMON ALIAS : DOCUMENT_IND DB2 ALIAS : ADDTNL_DCMTN_CD SAS ALIAS : DCMTN_CD STANDARD ALIAS : LINE_ADDTNL_CLM_DCMTN_IND_CD TITLE ALIAS : ADDTNL_DCMTN_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_ADDTNL_CLM_DCMTN_IND_CD. SOURCE : CWF EDIT RULES : In any case where more than one value is applicable, highest number is shown. CODE TABLE : LINE_ADDTNL_CLM_DCMTN_IND_TB 173. DMERC Line Screen Suspension Indicator Code 4 1949 1952 CHAR Effective with Version G, the code identifying the medical review (MR) screen that caused DMERC line item to suspend. DB2 ALIAS : SCRN_SUSPNSN_CD SAS ALIAS : SUSP_IND STANDARD ALIAS : DMERC_LINE_SCRN_SUSPNSN_IND_CD TITLE ALIAS : SCRN_SUSPNSN_IND LENGTH : 4 SOURCE : CWF CODE TABLE : DMERC_LINE_SCRN_SUSPNSN_IND_TB 174. DMERC Line Screen Result Indicator Code 1 1953 1953 CHAR Effective with Version G, code indicating the outcome of the medical review (MR) unit's evaluation of the DMERC line item. DB2 ALIAS : SCRN_RSLT_IND_CD SAS ALIAS : RSLT_IND STANDARD ALIAS : DMERC_LINE_SCRN_RSLT_IND_CD TITLE ALIAS : SCRN_RSLT_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_DME_SCRN_RSLT_IND_CD. SOURCE : CWF CODE TABLE : DMERC_LINE_SCRN_RSLT_IND_TB 175. DMERC Line Waiver Of Provider Liability Switch 1 1954 1954 CHAR Effective with Version G, the switch indicating the beneficiary was notified that the item, reported as a DMERC line item, may not be considered medically necessary and has agreed in writing to pay for the item. DB2 ALIAS : WVR_PRVDR_LBLTY_SW SAS ALIAS : WAIVERSW STANDARD ALIAS : DMERC_LINE_WVR_PRVDR_LBLTY_SW TITLE ALIAS : WAIVER_LBLTY_SW LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_DME_WVR_PRVDR_LBLTY_SW. SOURCE : CWF CODE TABLE : YES_NO_TB 176. DMERC Line Decision Indicator Switch 1 1955 1955 CHAR Effective with Version G, the switch identifying whether the DMERC claim represents an original decision or a reversal of an earlier decision on the original claim. DB2 ALIAS : DMERC_DCSN_IND_SW SAS ALIAS : DCSN_IND STANDARD ALIAS : DMERC_LINE_DCSN_IND_SW TITLE ALIAS : DCSN_IND LENGTH : 1 COMMENTS : Prior to Version H this field was named: CWFB_DME_DCSN_IND_SW. SOURCE : CWF CODE TABLE : DMERC_LINE_DCSN_IND_TB 177. Line Consolidated Billing Indicator Code 1 1956 1956 CHAR Effective 1/1/2004 with implementation of NCH/NMUD CR#1, this code is reflected on carrier & DMERC claims to identify those line item services (i.e. therapy and nonroutine supply services) that are subject to SNF and Home Health consolidated billing. If the line item service was paid by a carrier prior to the submission of the SNF or home health claim an adjustment for the carrier or DMERC claim will be submitted identifying those services that are subject to consolidated billing. NOTE1: Prior to 10/2005 (implementation of NCH/NMUD CR#2), this data was stored in position 245 (FILLER) of the line item trailer. Effective July 2005, this data will no longer be coming into the NCH. DB2 ALIAS : CNSLDTD_BLG_CD SAS ALIAS : LCNSLDTD STANDARD ALIAS : LINE_CNSLDTD_BLG_CD LENGTH : 1 CODE TABLE : LINE_CNSLDTD_BLG_TB 178. Line Duplicate Claim Check Indicator Code 1 1957 1957 CHAR Effective 1/1/2004 with the implementation of NCH/NMUD CR#1, the code used to identify an item or service that appeared to be a duplicate but has been reviewed by a carrier and appropriately approved for payment. NOTE1: Prior to 10/2005 (implementation of NCH/NMUD CR#2), this data was stored in position 246 (FILLER) on the line item trailer. DB2 ALIAS : DUP_CLM_CHK_IND_CD SAS ALIAS : DUP_CHK STANDARD ALIAS : LINE_DUP_CLM_CHK_IND_CD LENGTH : 1 SOURCE : CWF CODE TABLE : LINE_DUP_CLM_CHK_IND_TB 179. Line Hematocrit/Hemoglobin Test Type Code 2 1958 1959 CHAR Effective September 1, 2008 with the implementation of CR#3, the code used to identify which reading is reflected in the hematocrit/hemoglobin result number field on the noninstitutional claim. DB2 ALIAS : HCT_HGB_TYPE_CD SAS ALIAS : HTYPECD STANDARD ALIAS : LINE_HCT_HGB_TYPE_CD LENGTH : 2 CODE TABLE : LINE_HCT_HGB_TYPE_TB 180. Line Hematocrit/Hemoglobin Result Number 3 1960 1962 CHAR Effective September 1, 2008, with the implementation of CR#3, the number used to identify the most recent hematocrit or hemoglobin reading on the noninstitutional claim. NOTE: The hematocrit/hemoglobin test result field is a redefined field. The field is being defined as X(3) and redefined as numeric (99V9). A numeric test on the alphanumeric field is needed. Whenever a user wants to use the field they must test the alphanumeric field for numerics and if it is numeric then the 99V9 definition would be used. The older data will cause an abend if trying to process numeric data with characters. DB2 ALIAS : HCT_HGB_RSLT_NUM SAS ALIAS : HRSLTNUM STANDARD ALIAS : LINE_HCT_HGB_RSLT_NUM LENGTH : 3 181. Line Hematocrit/Hemoglobin Result Number -- Redefined 3 1963 1965 NUM Effective September 1, 2008, with the implementation of CR#3, the number used to identify the most recent hematocrit or hemoglobin reading on the noninstitutional claim. NOTE: The hematocrit/hemoglobin test result field is a redefined field. The field is being defined as X(3) and redefined as numeric (99V9). A numeric test on the alphanumeric field is needed. Whenever a user wants to use the field they must test the alphanumeric field for numerics and if it is numeric then the 99V9 definition would be used. The older data will cause an abend if trying to process numeric data with characters. DB2 ALIAS : HCT_HGB_RSLT_NUM SAS ALIAS : HRLSTNUM STANDARD ALIAS : LINE_HCT_HGB_RSLT_NUM_R LENGTH : 2.1 SIGNED : N REDEFINE : LINE_HCT_HGB_RSLT_NUM 182. Worker's Compensation Indicator Code 1 1966 1966 CHAR This indicator is used to determine whether the diagnosis codes on the claims are related to the diagnosis codes on the MSP auxiliary file in CWF. DB2 ALIAS : LINE_WC_IND_CD SAS ALIAS : WCINDCD STANDARD ALIAS : LINE_WC_IND_CD LENGTH : 1 CODE TABLE : LINE_WC_IND_TB 183. Line Paperwork (PWK) Code 2 1967 1968 CHAR Effective with CR#6, the code used to indicate a provider has submitted an electronic claim that requires additional documentation. DB2 ALIAS : LINE_PWK_CD STANDARD ALIAS : LINE_PWK_CD LENGTH : 2 CODE TABLE : LINE_PWK_TB 184. Line Unique Tracking Number 14 1969 1982 CHAR Effective with CR#7, the number assigned to each Power Mobility Device (PMD) prior authorization request. Prior to the NCH April release (CR#7), the PMD tracking number was stored in the demonstration trailer. The tracking number was reflected in the claim by demo # '60'. Effective with the CWF January release, demo '60' was implemented with CR7495 (Implementation of Prior Authorization for Power Mobility Devices (PMD) to facilitate a three year mandatory prior authori- zation process in 7 states. This initiative was designed as a tool to protect the Medicare trust fund by deterring fraudulent and abusive billing practices, and make the physician or treating practitioner more accountable for the items he or she orders to prevent improper payments. Under this demonstration for a PMD, a physician/treating practitioner must submit a request for prior authori- zation to support Medicare coverage requirements of the PMD item. Prior to CR#9, this field was named: LINE_PMD_TRKNG_NUM. DB2 ALIAS : LINE_UNIQ_TRKNG_NU SAS ALIAS : UNIQNUM STANDARD ALIAS : LINE_UNIQ_TRKNG_NUM LENGTH : 14 COMMENTS : (CMS CR7495) 185. Line Other Applied Indicator 1 Code 2 1983 1984 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND1 LENGTH : 2 186. Line Other Applied Indicator 2 Code 2 1985 1986 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND2 LENGTH : 2 SOURCE : CWF 187. Line Other Applied Indicator 3 Code 2 1987 1988 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND3 LENGTH : 2 SOURCE : CWF 188. Line Other Applied Indicator 4 Code 2 1989 1990 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND4 LENGTH : 2 SOURCE : CWF 189. Line Other Applied Indicator 5 Code 2 1991 1992 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND5 LENGTH : 2 SOURCE : CWF 190. Line Other Applied Indicator 6 Code 2 1993 1994 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND6 LENGTH : 2 SOURCE : CWF 191. Line Other Applied Indicator 7 Code 2 1995 1996 CHAR Effective with Version 'K', the code used to identify the reason the claim payment amount was adjusted during claims processing. Effective with Version L (January 2021 release), this field was expanded from 1 byte to 2 bytes. DB2 ALIAS : UNDEFINED SAS ALIAS : APLDIND7 LENGTH : 2 SOURCE : CWF 192. Line Other Applied 1 Amount 6 1997 2002 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_1_AMT SAS ALIAS : APLDAMT1 STANDARD ALIAS : LINE_OTHR_APLD_1_AMT LENGTH : 9.2 SIGNED : Y 193. Line Other Applied 2 Amount 6 2003 2008 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_2_AMT SAS ALIAS : APLDAMT2 STANDARD ALIAS : LINE_OTHR_APLD_2_AMT LENGTH : 9.2 SIGNED : Y 194. Line Other Applied 3 Amount 6 2009 2014 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_3_AMT SAS ALIAS : APLDAMT3 STANDARD ALIAS : LINE_OTHR_APLD_3_AMT LENGTH : 9.2 SIGNED : Y 195. Line Other Applied 4 Amount 6 2015 2020 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_4_AMT SAS ALIAS : APLDAMT4 STANDARD ALIAS : LINE_OTHR_APLD_4_AMT LENGTH : 9.2 SIGNED : Y 196. Line Other Applied 5 Amount 6 2021 2026 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_5_AMT SAS ALIAS : APLDAMT5 STANDARD ALIAS : LINE_OTHR_APLD_5_AMT LENGTH : 9.2 SIGNED : Y 197. Line Other Applied 6 Amount 6 2027 2032 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_6_AMT SAS ALIAS : APLDAMT6 STANDARD ALIAS : LINE_OTHR_APLD_6_AMT LENGTH : 9.2 SIGNED : Y 198. Line Other Applied 7 Amount 6 2033 2038 PACK Effective with Version 'K', the field used to identify amounts that were used to adjust the amount payable when processing the line item. DB2 ALIAS : OTHR_APLD_7_AMT SAS ALIAS : APLDAMT7 STANDARD ALIAS : LINE_OTHR_APLD_7_AMT LENGTH : 9.2 SIGNED : Y 199. Line FPS Model Number 2 2039 2040 CHAR Effective with Version 'K', this field identifies an FPS analytic model that identifies claims that may be high risk for fraud based on specific information. DB2 ALIAS : LINE_FPS_MODEL_NUM SAS ALIAS : LMODEL STANDARD ALIAS : LINE-FPS-MODEL-NUM LENGTH : 2 200. Line FPS Reason Code 3 2041 2043 CHAR Effective with Version 'K', this field identifies the reason codes used to explain why a claim was not paid or how the claim was paid. These codes also show the reason for any claim financial adjustment such as denial, reductions or increases in payment. DB2 ALIAS : LINE_FPS_RSN_CD SAS ALIAS : LFPSRSN STANDARD ALIAS : LINE-FPS-RSN-CD LENGTH : 3 CODE TABLE : CLM_ADJ_RSN_TB 201. Line FPS Remark Code 5 2044 2048 CHAR Effective with Version 'K', the codes used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. DB2 ALIAS : LINE_FPS_RMRK_CD SAS ALIAS : LFPSRMRK STANDARD ALIAS : LINE-FPS-RMRK-CD LENGTH : 5 CODE TABLE : CLM_RMTNC_ADVC_TB 202. Line FPS MSN 1 Code 5 2049 2053 CHAR Effective with Version 'K', the field used to identify the Medicare Secondary Notice Code. DB2 ALIAS : LINE_FPS_MSN_1_CD SAS ALIAS : LFPSMSN1 STANDARD ALIAS : LINE-FPS-MSN-1-CD LENGTH : 5 CODE TABLE : CLM_FPS_MSN_CD_TB 203. Line FPS MSN 2 Code 5 2054 2058 CHAR Effective with Version 'K', the field used to identify the Medicare Secondary Notice Code. DB2 ALIAS : LINE_FPS_MSN_2_CD SAS ALIAS : LFPSMSN2 STANDARD ALIAS : LINE-FPS-MSN-2-CD LENGTH : 5 CODE TABLE : CLM_FPS_MSN_CD_TB 204. DMERC Line Competitive Bidding Area (CBA) Code 5 2059 2063 CHAR Effective with CR#8, the code used to identify the Competitive Bidding Area (CBA). DB2 ALIAS : DMERC_LINE_CBA_CD SAS ALIAS : CBACD STANDARD ALIAS : DMERC_LINE_CBA_CD LENGTH : 5 CODE TABLE : DMERC_LINE_CBA_TB 205. DMERC Line Competitive Bidding Area (CBA) Date 8 2064 2071 NUM Effective with CR#8, the date used to identify the start date for a particular round of competitive bidding used to determine the eligibility for contract or grandfathering suppliers. DB2 ALIAS : DMERC_LINE_CBA_DT SAS ALIAS : CBADATE STANDARD ALIAS : DMERC_LINE_CBA_DT LENGTH : 8 SIGNED : N 206. Line Prior Authorization Indicator Code 4 2072 2075 CHAR Effective with CR#9 (October 2014 release), the indicator assigned by CMS for each prior authorization program to define the applicable line of business (i.e. Part A, Part B, DME, Home Health and Hospice). DB2 ALIAS : LINE_AUTHRZTN_CD SAS ALIAS : LPRIOR STANDARD ALIAS : LINE_PRIOR_AUTHRZTN_IND_CD LENGTH : 4 CODE TABLE : LINE_PRIOR_AUTHRZTN_TB 207. Line Representative Payee (RP) Indicator Code 1 2076 2076 CHAR Effective with CR#11, this field will be used to designate by- passing of the prior authorization processing for claims with a representative payee when an 'R' is present in the field. NOTE: Data will not start coming in until April 2016. This field was added to the January 2016 release because our workload (FA fix) will not allow us to implement another CR in April. DB2 ALIAS : LINE_RP_IND_CD SAS ALIAS : LRPIND STANDARD ALIAS : LINE_RP_IND_CD LENGTH : 1 SOURCE : CWF CODE TABLE : RP_IND_TB 208. Line Residual Payment Indicator Code 1 2077 2077 CHAR Effective with CR#11, this field is used by CWF claims processing for the purpose of bypassing its normal MSP editing that would otherwise apply for ongoing responsibility for medicals (ORM) or worker's compensation Medicare Set-Aside Arrangements (WCMSA). Normally, CWF does not allow a secondary payment on MSP involving ORM or WCMSA, so the residual payment indicator will be used to allow CWF to make an exception to its normal routine. DB2 ALIAS : LINE_RSDL_PMT_CD SAS ALIAS : LRSDLPMT STANDARD ALIAS : LINE_RSDL_PMT_IND_CD LENGTH : 1 SOURCE : CWF CODE TABLE : RSDL_PMT_IND_TB 209. Line Foreign Address Indicator 2 2078 2079 CHAR Effective with CR#12, this field is used to identify claims for expatriate beneficiaries (beneificiary whose permanent address is outside the U.S.) who purchased DMEPOS items that were furnished in the United States. DB2 ALIAS : FRGN_ADR_IND_CD SAS ALIAS : FRGNADR STANDARD ALIAS : DMERC_LINE_FRGN_ADR_IND_CD LENGTH : 2 COMMENTS : (CMS CR9468) - CWF July 2016 Release CODE TABLE : DMERC_LINE_FRGN_ADR_IND_TB 210. DMERC Line Railroad Board Exclusion Indicator Switch 1 2080 2080 CHAR Effective with CR#14 (April 2019 release), this field informs the Shared System Maintainer (SSM) and Common Working File (CWF) if the Railroad Board (RRB) beneficiary claim should either be in- cluded or excluded from Prior Authorization (PA) processing. For example, if the field is valued "Y", and it is an RRB bene- ficiary claim, it will be excluded from PA processing. DB2 ALIAS : UNDEFINED SAS ALIAS : DLEXCLSN LENGTH : 1 CODE TABLE : DMERC_LINE_RRB_EXCLSN_IND_TB 211. Line Voluntary Service Indicator Code 1 2081 2081 CHAR Effective with Version L (January 2021 release), this line level field will be used to identify if the service (Procedure Code) was voluntary or required. Valid values: V = A Voluntary procedure code Blank = A Required procedure code DB2 ALIAS : UNDEFINED SAS ALIAS : LVLNTRY STANDARD ALIAS : LINE_VLNTRY_SRVC_IND_CD LENGTH : 1 SOURCE : CWF CODE TABLE : LINE_VLNTRY_SRVC_IND_TB 212. 970 2082 3051 CHAR DB2 ALIAS : H_FILLER_9 LENGTH : 970 213. End of Record Code 3 18925 18927 CHAR Effective with Version 'I', the code used to identify the end of a record/segment or the end of the claim. DB2 ALIAS : END_REC_CD SAS ALIAS : EOR STANDARD ALIAS : END_REC_CD TITLE ALIAS : END_OF_REC LENGTH : 3 COMMENTS : Prior to Version I this field was named: END_REC_CNSTNT. SOURCE : NCH CODE TABLE : END_REC_TB QUERY: RIFQQ11, RIFQQ21 ON DB2T ***********END OF MAIN REPORT FOR RECORD: DMERC_CLM_REC*********** 1 TABLE OF CODES APPENDIX FOR RECORD: DMERC_CLM_REC, STATUS: PROD, VERSION: 21006 PRINTED: 01/29/2021, USER: F43D, DATA SOURCE: CA REPOSITORY ON DB2T BENE_CWF_LOC_TB Beneficiary Common Working File Location Table B = Mid-Atlantic C = Southwest D = Northeast E = Great Lakes F = Great Western G = Keystone H = Southeast I = South J = Pacific BENE_IDENT_TB Beneficiary Identification Code (BIC) Table Social Security Administration: A = Primary claimant B = Aged wife, age 62 or over (1st claimant) B1 = Aged husband, age 62 or over (1st claimant) B2 = Young wife, with a child in her care (1st claimant) B3 = Aged wife (2nd claimant) B4 = Aged husband (2nd claimant) B5 = Young wife (2nd claimant) B6 = Divorced wife, age 62 or over (1st claimant) B7 = Young wife (3rd claimant) B8 = Aged wife (3rd claimant) B9 = Divorced wife (2nd claimant) BA = Aged wife (4th claimant) BD = Aged wife (5th claimant) BG = Aged husband (3rd claimant) BH = Aged husband (4th claimant) BJ = Aged husband (5th claimant) BK = Young wife (4th claimant) BL = Young wife (5th claimant) BN = Divorced wife (3rd claimant) BP = Divorced wife (4th claimant) BQ = Divorced wife (5th claimant) BR = Divorced husband (1st claimant) BT = Divorced husband (2nd claimant) BW = Young husband (2nd claimant) BY = Young husband (1st claimant) C1-C9,CA-CZ = Child (includes minor, student or disabled child) D = Aged widow, 60 or over (1st claimant) D1 = Aged widower, age 60 or over (1st claimant) D2 = Aged widow (2nd claimant) D3 = Aged widower (2nd claimant) D4 = Widow (remarried after attainment of age 60) (1st claimant) D5 = Widower (remarried after attainment of age 60) (1st claimant) D6 = Surviving divorced wife, age 60 or over (1st claimant) D7 = Surviving divorced wife (2nd claimant) D8 = Aged widow (3rd claimant) D9 = Remarried widow (2nd claimant) DA = Remarried widow (3rd claimant) DD = Aged widow (4th claimant) DG = Aged widow (5th claimant) DH = Aged widower (3rd claimant) DJ = Aged widower (4th claimant) DK = Aged widower (5th claimant) DL = Remarried widow (4th claimant) DM = Surviving divorced husband (2nd claimant) DN = Remarried widow (5th claimant) DP = Remarried widower (2nd claimant) DQ = Remarried widower (3rd claimant) DR = Remarried widower (4th claimant) DS = Surviving divorced husband (3rd claimant) DT = Remarried widower (5th claimant) DV = Surviving divorced wife (3rd claimant) DW = Surviving divorced wife (4th claimant) DX = Surviving divorced husband (4th claimant) DY = Surviving divorced wife (5th claimant) DZ = Surviving divorced husband (5th claimant) E = Mother (widow) (1st claimant) E1 = Surviving divorced mother (1st claimant) E2 = Mother (widow) (2nd claimant) E3 = Surviving divorced mother (2nd claimant) E4 = Father (widower) (1st claimant) E5 = Surviving divorced father (widower) (1st claimant) E6 = Father (widower) (2nd claimant) E7 = Mother (widow) (3rd claimant) E8 = Mother (widow) (4th claimant) E9 = Surviving divorced father (widower) (2nd claimant) EA = Mother (widow) (5th claimant) EB = Surviving divorced mother (3rd claimant) EC = Surviving divorced mother (4th claimant) ED = Surviving divorced mother (5th claimant EF = Father (widower) (3rd claimant) EG = Father (widower) (4th claimant) EH = Father (widower) (5th claimant) EJ = Surviving divorced father (3rd claimant) EK = Surviving divorced father (4th claimant) EM = Surviving divorced father (5th claimant) F1 = Father F2 = Mother F3 = Stepfather F4 = Stepmother F5 = Adopting father F6 = Adopting mother F7 = Second alleged father F8 = Second alleged mother J1 = Primary prouty entitled to HIB (less than 3 Q.C.) (general fund) J2 = Primary prouty entitled to HIB (over 2 Q.C.) (RSI trust fund) J3 = Primary prouty not entitled to HIB (less than 3 Q.C.) (general fund) J4 = Primary prouty not entitled to HIB (over 2 Q.C.) (RSI trust fund) K1 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (1st claimant) K2 = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (1st claimant) K3 = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (1st claimant) K4 = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (1st claimant) K5 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (2nd claimant) K6 = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (2nd claimant) K7 = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (2nd claimant) K8 = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (2nd claimant) K9 = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (3rd claimant) KA = Prouty wife entitled to HIB (over 2 Q.C.) (RSI trust fund) (3rd claimant) KB = Prouty wife not entitled to HIB (less than 3 Q.C.) (general fund) (3rd claimant) KC = Prouty wife not entitled to HIB (over 2 Q.C.) (RSI trust fund) (3rd claimant) KD = Prouty wife entitled to HIB (less than 3 Q.C.) (general fund) (4th claimant) KE = Prouty wife entitled to HIB (over 2 Q.C (4th claimant) KF = Prouty wife not entitled to HIB (less than 3 Q.C.)(4th claimant) KG = Prouty wife not entitled to HIB (over 2 Q.C.)(4th claimant) KH = Prouty wife entitled to HIB (less than 3 Q.C.)(5th claimant) KJ = Prouty wife entitled to HIB (over 2 Q.C.) (5th claimant) KL = Prouty wife not entitled to HIB (less than 3 Q.C.)(5th claimant) KM = Prouty wife not entitled to HIB (over 2 Q.C.) (5th claimant) M = Uninsured-not qualified for deemed HIB M1 = Uninsured-qualified but refused HIB T = Uninsured-entitled to HIB under deemed or renal provisions TA = MQGE (primary claimant) TB = MQGE aged spouse (first claimant) TC = MQGE disabled adult child (first claimant) TD = MQGE aged widow(er) (first claimant) TE = MQGE young widow(er) (first claimant) TF = MQGE parent (male) TG = MQGE aged spouse (second claimant) TH = MQGE aged spouse (third claimant) TJ = MQGE aged spouse (fourth claimant) TK = MQGE aged spouse (fifth claimant) TL = MQGE aged widow(er) (second claimant) TM = MQGE aged widow(er) (third claimant) TN = MQGE aged widow(er) (fourth claimant) TP = MQGE aged widow(er) (fifth claimant) TQ = MQGE parent (female) TR = MQGE young widow(er) (second claimant) TS = MQGE young widow(er) (third claimant) TT = MQGE young widow(er) (fourth claimant) TU = MQGE young widow(er) (fifth claimant) TV = MQGE disabled widow(er) fifth claimant TW = MQGE disabled widow(er) first claimant TX = MQGE disabled widow(er) second claimant TY = MQGE disabled widow(er) third claimant TZ = MQGE disabled widow(er) fourth claimant T2-T9 = Disabled child (second to ninth claimant) W = Disabled widow, age 50 or over (1st claimant) W1 = Disabled widower, age 50 or over (1st claimant) W2 = Disabled widow (2nd claimant) W3 = Disabled widower (2nd claimant) W4 = Disabled widow (3rd claimant) W5 = Disabled widower (3rd claimant) W6 = Disabled surviving divorced wife (1st claimant) W7 = Disabled surviving divorced wife (2nd claimant) W8 = Disabled surviving divorced wife (3rd claimant) W9 = Disabled widow (4th claimant) WB = Disabled widower (4th claimant) WC = Disabled surviving divorced wife (4th claimant) WF = Disabled widow (5th claimant) WG = Disabled widower (5th claimant) WJ = Disabled surviving divorced wife (5th claimant) WR = Disabled surviving divorced husband (1st claimant) WT = Disabled surviving divorced husband (2nd claimant) Railroad Retirement Board: NOTE: Employee: a Medicare beneficiary who is still working or a worker who died before retirement Annuitant: a person who retired under the railroad retirement act on or after 03/01/37 Pensioner: a person who retired prior to 03/01/37 and was included in the railroad retirement act 10 = Retirement - employee or annuitant 80 = RR pensioner (age or disability) 14 = Spouse of RR employee or annuitant (husband or wife) 84 = Spouse of RR pensioner 43 = Child of RR employee 13 = Child of RR annuitant 17 = Disabled adult child of RR annuitant 46 = Widow/widower of RR employee 16 = Widow/widower of RR annuitant 86 = Widow/widower of RR pensioner 43 = Widow of employee with a child in her care 13 = Widow of annuitant with a child in her care 83 = Widow of pensioner with a child in her care 45 = Parent of employee 15 = Parent of annuitant 85 = Parent of pensioner 11 = Survivor joint annuitant (reduced benefits taken to insure benefits for surviving spouse) BENE_MDCR_STUS_TB CWF Beneficiary Medicare Status Table 10 = Aged without ESRD 11 = Aged with ESRD 20 = Disabled without ESRD 21 = Disabled with ESRD 31 = ESRD only BENE_PRMRY_PYR_TB Beneficiary Primary Payer Table A = Working aged bene/spouse with employer group health plan (EGHP) B = End stage renal disease (ESRD) beneficiary in the 18 month coordination period with an employer group health plan C = Conditional payment by Medicare; future reimbursement expected D = Automobile no-fault (eff. 4/97; Prior to 3/94, also included any liability insurance) E = Workers' compensation F = Public Health Service or other federal agency (other than Dept. of Veterans Affairs) G = Working disabled bene (under age 65 with LGHP) H = Black Lung I = Dept. of Veterans Affairs J = Any liability insurance (eff. 3/94 - 3/97) L = Any liability insurance (eff. 4/97) (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) M = Override code: EGHP services involved (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) N = Override code: non-EGHP services involved (eff. 12/90 for carrier claims and 10/93 for FI claims; obsoleted for all claim types 7/1/96) BLANK = Medicare is primary payer (not sure of effective date: in use 1/91, if not earlier) ***Prior to 12/90*** Y = Other secondary payer investigation shows Medicare as primary payer Z = Medicare is primary payer NOTE: Values C, M, N, Y, Z and BLANK indicate Medicare is primary payer. (values Z and Y were used prior to 12/90. BLANK was suppose to be effective after 12/90, but may have been used prior to that date.) BENE_RACE_TB Beneficiary Race Table 0 = Unknown 1 = White 2 = Black 3 = Other 4 = Asian 5 = Hispanic 6 = North American Native BENE_SEX_IDENT_TB Beneficiary Sex Identification Table 1 = Male 2 = Female 0 = Unknown BETOS_TB BETOS Table M1A = Office visits - new M1B = Office visits - established M2A = Hospital visit - initial M2B = Hospital visit - subsequent M2C = Hospital visit - critical care M3 = Emergency room visit M4A = Home visit M4B = Nursing home visit M5A = Specialist - pathology M5B = Specialist - psychiatry M5C = Specialist - opthamology M5D = Specialist - other M6 = Consultations P0 = Anesthesia P1A = Major procedure - breast P1B = Major procedure - colectomy P1C = Major procedure - cholecystectomy P1D = Major procedure - turp P1E = Major procedure - hysterectomy P1F = Major procedure - explor/decompr/excisdisc P1G = Major procedure - Other P2A = Major procedure, cardiovascular-CABG P2B = Major procedure, cardiovascular-Aneurysm repair P2C = Major Procedure, cardiovascular-Thromboendarterectomy P2D = Major procedure, cardiovascualr-Coronary angioplasty (PTCA) P2E = Major procedure, cardiovascular-Pacemaker insertion P2F = Major procedure, cardiovascular-Other P3A = Major procedure, orthopedic - Hip fracture repair P3B = Major procedure, orthopedic - Hip replacement P3C = Major procedure, orthopedic - Knee replacement P3D = Major procedure, orthopedic - other P4A = Eye procedure - corneal transplant P4B = Eye procedure - cataract removal/lens insertion P4C = Eye procedure - retinal detachment P4D = Eye procedure - treatment of retinal lesions P4E = Eye procedure - other P5A = Ambulatory procedures - skin P5B = Ambulatory procedures - musculoskeletal P5C = Ambulatory procedures - inguinal hernia repair P5D = Ambulatory procedures - lithotripsy P5E = Ambulatory procedures - other P6A = Minor procedures - skin P6B = Minor procedures - musculoskeletal P6C = Minor procedures - other (Medicare fee schedule) P6D = Minor procedures - other (non-Medicare fee schedule) P7A = Oncology - radiation therapy P7B = Oncology - other P8A = Endoscopy - arthroscopy P8B = Endoscopy - upper gastrointestinal P8C = Endoscopy - sigmoidoscopy P8D = Endoscopy - colonoscopy P8E = Endoscopy - cystoscopy P8F = Endoscopy - bronchoscopy P8G = Endoscopy - laparoscopic cholecystectomy P8H = Endoscopy - laryngoscopy P8I = Endoscopy - other P9A = Dialysis services (medicare fee schedule) P9B = Dialysis services (non-medicare fee schedule) I1A = Standard imaging - chest I1B = Standard imaging - musculoskeletal I1C = Standard imaging - breast I1D = Standard imaging - contrast gastrointestinal I1E = Standard imaging - nuclear medicine I1F = Standard imaging - other I2A = Advanced imaging - CAT/CT/CTA: brain/head/neck I2B = Advanced imaging - CAT/CT/CTA: other I2C = Advanced imaging - MRI/MRA: brain/head/neck I2D = Advanced imaging - MRI/MRA: other I3A = Echography/ultrasonography - eye I3B = Echography/ultrasonography - abdomen/pelvis I3C = Echography/ultrasonography - heart I3D = Echography/ultrasonography - carotid arteries I3E = Echography/ultrasonography - prostate, transrectal I3F = Echography/ultrasonography - other I4A = Imaging/procedure - heart including cardiac catheterization I4B = Imaging/procedure - other T1A = Lab tests - routine venipuncture (non Medicare fee schedule) T1B = Lab tests - automated general profiles T1C = Lab tests - urinalysis T1D = Lab tests - blood counts T1E = Lab tests - glucose T1F = Lab tests - bacterial cultures T1G = Lab tests - other (Medicare fee schedule) T1H = Lab tests - other (non-Medicare fee schedule) T2A = Other tests - electrocardiograms T2B = Other tests - cardiovascular stress tests T2C = Other tests - EKG monitoring T2D = Other tests - other D1A = Medical/surgical supplies D1B = Hospital beds D1C = Oxygen and supplies D1D = Wheelchairs D1E = Other DME D1F = Prosthetic/Orthotic devices D1G = Drugs Administered through DME O1A = Ambulance O1B = Chiropractic O1C = Enteral and parenteral O1D = Chemotherapy O1E = Other drugs O1F = Hearing and speech services O1G = Immunizations/Vaccinations Y1 = Other - Medicare fee schedule Y2 = Other - non-Medicare fee schedule Z1 = Local codes Z2 = Undefined codes CARR_CLM_ENTRY_TB Carrier Claim Entry Table 1 = Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit) 3 = Full credit 5 = Replacement debit 9 = Accrete bill history only (internal; effective 2/22/91) CARR_CLM_HOSPC_OVRRD_IND_TB Carrier Claim Hospice Override Indicator Table 0 = No Investigation 1 = Hospice investigation shown not applicable to this claim. CARR_CLM_MCO_OVRRD_IND_TB Carrier Claim MCO Override Indicator Table 0 = No Investigation 1 = MCO Investigation does not apply to this claim. CARR_CLM_PMT_DNL_TB Carrier Claim Payment Denial Table Valid values effective 1/2011 (2-byte values are replacing the character values) 0 = Denied 1 = Physician/supplier 2 = Beneficiary 3 = Both physician/supplier and beneficiary 4 = Hospital (hospital based physicians) 5 = Both hospital and beneficiary 6 = Group practice prepayment plan 7 = Other entries (e.g. Employer, union) 8 = Federally funded 9 = PA service A = Allowed B = Benefits Exhausted C = Non-convered Care D = Denied due to demonstration involvement (eff. 5/97) E = MSP Cost Avoided - First Claim Development F = MSP Cost Avoided - Trauma Code Development G = Secondary Claims Investigation H = Self Reports J = 411.25 K = Insurer Voluntary Reporting L = Clinical Lab Improvement Amendment (CLIA) M = Multiple submittal (i.e. duplicate line item) N = Medical Necessity O = Other P = Physician ownership denial (eff 3/92) Q = MSP Cost Avoided - Employer Voluntary Reporting R = Reprocessed adjustment based on subsequent reprocessing of claim S = Secondary Payer T = MSP cost avoided - IEQ contractor (eff. 7/96) U = MSP cost avoided - HMO rate cell adjustment (eff. 7/96) V = MSP cost avoided - litigation settlement (eff. 7/96) X = MSP cost avoided - generic Y = MSP cost avoided - IRS/SSA data match project Z = Zero payment, allowed test 00= MSP cost avoided - COB Contractor 12= MSP cost avoided - BC/BS Voluntary Agreements 13= MSP cost avoided - Office of Personnel Management 14= MSP cost avoided - Workman's Compensation (WC) Datamatch 15= MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) (eff. 4/2006) 16= MSP cost avoided - Liability Insurer VDSA (eff.4/2006) 17= MSP cost avoided - No-Fault Insurer VDSA (eff.4/2006) 18= MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement (eff.4/2006) 19 = MSP cost avoided - Worker's Compensation Medicare Set-Aside Arrangement (eff. 4/2006) 21= MSP cost avoided - MIR Group Health Plan (eff.1/2009) 22= MSP cost avoided - MIR non-Group Health Plan (eff.1/2009) 25= MSP cost avoided - Recovery Audit Contractor - California (eff.10/2005) 26= MSP cost avoided - Recovery Audit Contractor - Florida (eff.10/2005) 39 = MSP Cost Avoided - GHP Recovery 41 = MSP Cost Avoided - NGHP Non-ORM 42 = MSP Cost Avoided - NGHP ORM Recovery 43 = MSP Cost Avoided - COBC/Medicare Part C/Medicare Advantage NOTE: Effective 4/1/02, the Carrier claim payment denial code was expanded to a 2-byte field. The NCH instituted a crosswalk from the 2-byte code to a 1-byte character code. Below are the character codes (found in NCH & NMUD). At some point, NMUD will carry the 2-byte code but NCH will continue to have the 1-byte character code. ! = MSP cost avoided - COB Contractor ('00' 2-byte code) @ = MSP cost avoided - BC/BS Voluntary Agreements ('12' 2-byte code) # = MSP cost avoided - Office of Personnel Management ('13' 2-byte code) $ = MSP cost avoided - Workman's Compensation (WC) Datamatch ('14' 2-byte code) * = MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) ('15' 2-byte code) (eff. 4/2006) ( = MSP cost avoided - Liability Insurer VDSA ('16' 2-byte code) (eff. 4/2006) ) = MSP cost avoided - No-Fault Insurer VDSA ('17' 2-byte code) (eff. 4/2006) + = MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement ('18' 2 -byte code) (eff. 4/2006) < = MSP cost avoided - MIR Group Health Plan ('21' 2-byte code) (eff. 1/2009) > = MSP cost avoided - MIR non-Group Health Plan ('22' 2-byte code) (eff. 1/2009) % = MSP cost avoided - Recovery Audit Contractor - - California ('25' 2-byte code) (eff. 10/2005) & = MSP cost avoided - Recovery Audit Contractor - Florida ('26' 2-byte code) (eff. 10/2005) CARR_CLM_PRVDR_ASGNMT_IND_TB Carrier Claim Provider Assignment Code Table A = Assigned claim N = Non-assigned claim CARR_NUM_TB Carrier Number/MAC Table 00510 = Alabama - CAHABA (eff. 1983; term. 05/2009) (replaced by MAC #10102 -- see below) 00511 = Georgia - CAHABA (eff. 1998; term. 06/2009) (replaced by MAC #10202 -- see below) 00512 = Mississippi - CAHABA (eff. 2000) 00520 = Arkansas BC/BS (eff. 1983) 00521 = New Mexico - Arkansas BC/BS (eff. 1998; term. 02/2008) (replaced by MAC #04202 -- see below) 00522 = Oklahoma - Arkansas BC/BS (eff. 1998; term. 02/2008) (replaced by MAC #04302 -- see below) 00523 = Missouri East - Arkansas BC/BS (eff. 1999; term. 02/2008) (replaced by MAC #05392 -- see below) 00524 = Rhode Island - Arkansas BC/BS (eff. 2004; term. 01/2009) (replaced by MAC #14402 -- see below) 00528 = Louisiana - Arkansas BS (eff. 1984) 00542 = California BS (eff. 1983; term. 05/2009) 00550 = Colorado BS (eff. 1983; term. 11/1994) 00570 = Delaware - Pennsylvania BS (eff. 1983; term. 07/1997) 00580 = District of Columbia - Pennsylvania BS (eff. 1983; term. 08/1997) 00590 = Florida - First Coast (eff. 1983; term. 01/2009) (replaced by MAC #09102 -- see below) 00591 = Connecticut - First Coast (eff. 2000; term. 07/2008) (replaced by MAC #13102 -- see below) 00621 = Illinois BS - HCSC (eff. 1983; term. 08/1997) 00623 = Michigan - Illinois Blue Shield (eff. 1995; term. 08/1997) 00630 = Indiana - Administar (eff. 1983) (term. 08/19/2012) (replaced by MAC #08102 -- see below) 00635 = DMERC-B - Administar (eff. 1993; term. 06/2006) (replaced by MAC #17003 -- see below) 00640 = Iowa - Wellmark, Inc. (eff. 1983; term. 11/1996) 00645 = Nebraska - Iowa BS (eff. 1985; term. 11/1994) 00650 = Kansas BCBS (eff. 1983) (term. 02/2008) (replaced by MAC #05202 -- see below) 00651 = Missouri - Kansas BCBS (eff. 1983; term. 02/2008) (replaced by MAC #05202 -- see below) 00655 = Nebraska - Kansas BC/BS (eff. 1988; term. 02/2008) (replaced by MAC #05402 -- see below) 00660 = Kentucky - Administar (eff. 1983; term. 04/2011) 00662 = PFDC (Floyd Epps) (terminated) 00663 = FQHC Pilot Demo (CAFM - Ayers-Ramsey) (term. 11/2011) 00690 = Maryland BS (terminated) 00691 = CAREFIRST - CWF (terminated) 00700 = Massachusetts BS (eff. 1983; term. 11/1996) 00710 = Michigan BS (eff. 1983; term. 09/2000) 00720 = Minnesota BS (eff. 1983; term. 09/2000) 00740 = Western Missouri - Kansas BS (eff. 1983; term. 06/1997) (replaced by MAC #05302 -- see below) 00751 = Montana BC/BS (eff. 1983; term. 11/2006) (replaced by MAC # 03202 -- see below) 00770 = New Hampshire/Vermont Physician Services (eff. 1983; term. 12/1988) 00780 = New Hampshire - Massachusetts BS (eff. 1985; term. 04/1997) 00781 = Vermont - Massachusetts BS (eff. 1985; term. 06/1997) 00801 = New York - Healthnow (eff. 1983; term. 08/2008) (replaced by MAC #13282 -- see below) 00803 = New York - Empire BS (eff. 1983; term. 07/2008) (replaced by MAC #13202 -- see below) 00804 = New York - Rochester BS (term. 02/1999) (replaced by MAC # 12402 -- see below) 00805 = New Jersey - Empire BS (eff. 3/99; term. 11/2008) (replaced by MAC # 12402 -- see below) 00811 = DMERC (A) - Healthnow (eff. 2000; term. 06/2006) (replaced by MAC #16003 -- see below) 00820 = North Dakota - Noridian (eff. 1983; term. 11/2006) (replaced by MAC #03302 -- see below) 00823 = Utah - Noridian (eff. 12/1/2005; term. 11/2006) (replaced by MAC #03502 -- see below) 00824 = Colorado - Noridian (eff. 1995; term. 02/2008) (term. 2008) (replaced by MAC #04102 -- see below) 00825 = Wyoming - Noridian (eff. 1990; term. 11/2006) (replaced by MAC #03602 -- see below) 00826 = Iowa - Noridian (eff. 1999; term. 01/2008) (replaced by MAC #05102 -- see below) 00831 = Alaska - Noridian (eff. 1998) 00832 = Arizona - Noridian (eff. 1998; term. 11/2006) (replaced by MAC # 03102 -- see below) 00833 = Hawaii - Noridian (eff. 1998; term. 07/2008) (replaced by MAC # 01202 -- see below) 00834 = Nevada - Noridian (eff. 1998; term. 07/2008) (replaced by MAC # 01302 -- see below) 00835 = Oregon - Noridian (eff. 1998) 00836 = Washington - Noridian (eff. 1998) 00860 = New Jersey - Pennsylvania BS (eff. 1988; term. 02/1998) 00865 = Pennsylvania - Highmark (eff. 1983; term. 12/2008) (replaced by MAC # 12502 -- see below) 00870 = Rhode Island BS (eff. 1983; term. 02/1999) 00880 = South Carolina - Palmetto (eff. 1983; term. 06/2011) 00881 = South Carolina BS-P&E (terminated) 00882 = RRB - South Carolina PGBA (eff. 2000) 00883 = Ohio - Palmetto (eff. 2002; term. 06/2011) 00884 = West Virginia - Palmetto (eff. 2002; term. 06/2011) 00885 = DMERC C - Palmetto (eff. 1993; term. 05/2006) (replaced by MAC #18003 -- see below) 00888 = PLAMETTO DRUGS (terminated) 00889 = South Dakota - Noridian (eff. 4/1/2006; term. 11/2006) (replaced by MAC # 03402 -- see below) 00900 = Texas - Trailblazer (eff. 1983; term. 06/2008) (replaced by MAC # 04402 -- see below) 00901 = Maryland - Trailblazer (eff. 1995; term. 07/2008) (replaced by MAC # 12302 -- see below) 00902 = Delaware - Trailblazer (eff. 1998; term. 07/2008) (replaced by MAC # 12102 -- see below) 00903 = District of Columbia - Trailblazer (eff. 1998; term. 07/2008) (replaced by MAC # 12202 -- see below) 00904 = Virginia - Trailblazer (eff. 2000; term. 03/2011) (replaced by MAC # 11302 -- see below) 00910 = Utah BS (eff. 1983; term. 09/2006) 00930 = Washington BS (Washington Phy. Ser.) (term. 07/1998) 0093Q = Washington-Whatcom County BS (term. 10/1998) 0093R = Washington-Yakima County BS (term. 09/2000) 00931 = Washington-Lewis County BS 00932 = Washington BS 00934 = Washington-Chelan County BS 00935 = Washington-Kisap County BS (term. 12/1994) 00936 = Washington-Spokane County BS 0093B = Washington-Clallam County BS (terminated) 0093C = Washington-Clark County BS (terminated) 0093D = Washington-Columbia County BS (terminated) 0093E = Washington-CO WLITZ County BS (terminated) 0093F = Washington-Grays Harbor County BS (terminated) 0093G = Washington-Jefferson County BS (terminated) 0093H = Washington-Kittitas County BS (terminated) 0093I = Washington-Lewis County BS (terminated) 0093J = Washington-Pacific County BS (terminated) 0093K = Washington-Tacoma BS (terminated) 0093L = Washington-Skagit County BS (terminated) 0093M = Washington-Snohomish County BS (terminated) 0093N = Washington-Thurston County BS (terminated) 0093P = Washington-Walla Walla County BS (term. 11/2000) 00950 = Wisconsin - Milwaukee Surgical (term. 07/1997) 00951 = Wisconsin - Wisconsin Phy Svc (eff. 1983) 00952 = Illinois - Wisconsin Phy Svc (eff. 1999) 00953 = Michigan - Wisconsin Phy Svc (eff. 1999) (term. 07/15/2012) (replaced by MAC #08202 -- see below) 00954 = Minnesota - Wisconsin Phy Svc (eff. 2000) 00960 = WPS Part D GAP (CAFM)(Truffer) (eff. 01/2010) 00973 = Puerto Rico - Triple S, Inc. (eff. 1983; term. 02/2009) (replaced by MAC # 09302 -- see below) 00974 = Virgin Islands - Triple S, Inc. (term. 02/2009) 01020 = Alaska - AETNA (eff. 1983; term. 07/1997) 01030 = Arizona - AETNA (eff. 1983; term. 07/1997) 01040 = Georgia - AETNA (eff. 1988; term. 07/1997) 01070 = Connecticut - AETNA (term. 07/1997) 01120 = Hawaii - AETNA (eff. 1983; term. 1997) 01290 = Nevada - AETNA (eff. 1983; term. 10/1994) 01360 = New Mexico - AETNA (eff. 1986; term. 07/1998) 01370 = Oklahoma - AETNA (eff. 1983; term. 02/1996) 01380 = Oregon - AETNA (eff. 1983; term. 09/2000) 01390 = Washington - AETNA (eff. 1994; term. 09/2000) 02050 = California - TOLIC (eff. 1983; term. 09/1991) 02051 = OCCIDENTAL - P&E (eff. 1983; term. 12/1998) 02831 = WEST.CONSORT.OCCIDENTAL-ALASKA (term. 07/2002) 02832 = WEST.CONSORT.OCCIDENTAL-ALASKA (term. 07/2002) 02833 = WEST.CONSORT.OCCIDENTAL-ALASKA 02834 = WEST.CONSORT.OCCIDENTAL-ALASKA (term. 11-1988) 02835 = WEST.CONSORT.OCCIDENTAL-ALASKA 02836 = WEST.CONSORT.OCCIDENTAL-ALASKA (term. 12-1988) 03070 = Connecticut General Life Insurance Co. (eff. 1983; term. 04/1997) 04110 = GEORGIA - JOHN HANCOCK (term. 04/1997) 04220 = MASSACHUSETTS - JOHN HANCOCK (term. 04/1997) 05130 = Idaho - CIGNA (eff. 1983) 05320 = New Mexico - Equitable Insurance (eff. 1983; term. 1985) 05330 = NEW YORK - Equitable 05440 = Tennessee - CIGNA (eff. 1983; term. 08/2009) (replaced by MAC #10302 - see below) 05530 = Wyoming - Equitable Insurance (eff. 1983) (term. 1989) 05535 = North Carolina - CIGNA (eff. 1988) 05655 = DMERC-D Alaska - CIGNA (eff. 1993; term. 09/2006) (replaced by MAC #19003 -- see below) 06140 = ILLINOIS - CONTINENTAL CASUALTY (term. 11/2008) 07180 = Kentucky - Metropolitan (term. 11/2000) 07330 = New York - Metropolitan (term. 08/1994) 08190 = Louisiana - Pan American 09200 = Maine-Union Mutual (terminated) 10070 = RRB-United Healthcare (term. 02/2004) 10071 = RRB-United Healthcare (terminated) 10072 = RRB-United Healthcare (terminated) 10073 = RRB-United Healthcare (terminated) 10074 = RRB-United Healthcare (term. 09/2000) 10075 = RRB-United Healthcare (terminated) 10076 = RRB-United Healthcare (terminated) 10230 = Connecticut - Metra Health (eff. 1986) (terminated) 10240 = Minnesota - Metra Health (eff. 1983) (term. 08/1994) 10250 = Mississippi - Metra Health (eff. 1983) (term. 09/2000) 10490 = Virginia - Metra Health (eff. 1983) (term. 05/1997) 10555 = DMERC A - United Healthcare (eff. 1993) (term. 12/1993) 11260 = General American Life of Missouri (eff. 1983; term. 1998) 14330 = New York - GHI (eff. 1983; term. 07/2008) (replaced by MAC #13292 -- see below) 16360 = Ohio - Nationwide Insurance Co. (eff. 1983) (term. 2002) 16510 = West Virginia - Nationwide Insurance Co. (eff. 1983) (term. 2002) 21200 = Maine - Massachusetts BS (eff. 1983) (term. 1998) 25370 = Okalhoma Dept of Public Welfare (terminated) 31140 = N. California - National Heritage Ins. (eff. 1997; term. 08/2008) (replaced by MAC #01102 -- see below) 31142 = Maine - National Heritage Ins. (eff. 1998; term. 05-2009) (replaced with MAC # 14102 - see below) 31143 = Massachusetts - National Heritage Ins. (eff. 1998; term. 05-2009) (replaced with MAC # 14202 - see below) 31144 = New Hampshire - National Heritage Ins. (eff. 1998; term. 05-2009) (replaced with MAC # 14302 - see below) 31145 = Vermont - National Heritage Ins. (eff. 1998; term. 05-2009) 31146 = So. California - NHIC (eff. 2000; term. 08/2008) 41260 = Missouri-General American (terminated) 80884 = Contractor ID for Physician Risk Adjust- ment Data (data not sent through CWF; but through Palmetto) 88001 = Retiree Drugs Subsidy Program (terminated) 88002 = Retiree Drugs Subsidy Program (ViPS) (CAFM) (terminated) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Medicare Administrative Contractors (MACs) JURISDICTION 1 -- Part B MACs 01002 = J1 Roll-up 01102 = California (eff. 9/1/08) (replaces carrier #00832) 01192 = Palmetto GBA J1 (S CA) (eff. 09/01/2008) 01202 = Hawaiia (eff. 8/1/08) (replaces carrier #00833) 01302 = Nevada (eff. 8/1/08) (replaces carrier #00834) 02002 = JF Roll-up (2/3) 02102 = Alaska - Noridian Admin Svcs (eff. 02/01/2012) 02202 = Idaho - Noridian Admin Svcs (eff. 02/01/2012) 02302 = Oregon - Noridian Admin Svcs (eff. 02/01/2012) 02402 = Washington - Noridian Admin Svcs (eff. 02/01/2012) JURISDICTION 3 -- Part B MACs 03002 = JF Roll-up (2/3) (orig. J3) 03102 = Arizona (eff. 12/1/06) (replaces carrier #00832) 03202 = Montana (eff. 12/1/06) (replaces carrier #00751) 03302 = N. Dakota (eff. 12/1/06) (replaces carrier #00820) 03402 = S. Dakota (eff. 12/1/06) (replaces carrier #00889) 03502 = Utah (eff. 12/1/06) (replaces carrier #00823) 03602 = Wyoming (eff. 12/1/06) (replaces carrier #00825) JURISDICTION 4 -- Part B MACs 04002 = J4 Roll-up 04102 = Colorado (eff. 03/01/2008) (replaces carrier #00550) (terminated) 04202 = New Mexico (eff. 03/01/2008) (replaces carrier #00521) 04302 = Oklahoma (eff. 03/01/2008) (replaces carrier #00522) 04402 = Texas (eff. 06/01/2008) (replaces carrier #00900) JH Roll-up (4/7) 04112 = Colorado - Novitas Solutions JH (eff. 11/17/2012) 04212 = New Mexico - Novitas Solutions JH (eff. 11/17/2012) 04312 = Oklahoma - Novitas Solutions JH (eff. 11/17/2012) 04412 = Texas - Novitas Solutions JH (eff. 11/17/2012) JURISDICTION 5 -- Part B MACs 05002 = J5 Roll-up 05102 = Iowa (eff.2/1/08) (replaces carrier #00826) 05202 = Kansas (eff. 3/1/08) (replaces carrier #00650) 05302 = W. Missouri (eff. 3/1/08) (replaces carrier #00651 or 00740) 05392 = E. Missouri (eff. 6/1/08) (replaces carrier #00523) 05402 = Nebraska (eff. 3/1/08) (replaces carrier #00655) 06002 = J6 Roll-up 06102 = Illinois 06202 = Minnesota 06302 = Wisconsin 07002 = JH Roll-up (4/7) 07102 = Arkansas - Novitas Solutions JH (eff. 08/11/2012) (CR7812) 07202 = Louisiana - Novitas Solutions JH (eff. 08/11/2012) 07302 = Mississipppi - Novitas Solutions JH (eff. 10/20/2012) JURISDICTION 8 -- Part B MACs 08002 = J8 Roll-up 08102 = Indiana (eff.8/20/2012) (replaces carrier #00630) 08202 = Michigan (eff.7/16/2012) (replaces carrier #00953) JURISDICTION 9 -- Part B MACs 09002 = J9 Roll-up 09102 = Florida - First Coast (eff. 02/2009) (replaces carrier #00590) 09202 = Puerto Rico - First Coast (eff.03/2009) (replaces carrier #00973) 09302 = Virgin Island - First Coast (eff.03/2009) (replaces carrier #00974) JURISDICTION 10 -- Part B MACs 10002 = J10 Roll-up 10102 = Alabama (eff.5/4/09) (replaces carrier #00510) 10202 = Georgia (eff.8/3/09) (replaces carrier #00511) 10302 = Tennessee (eff.9/1/09) (replaces carrier #05440) COB Contractor Numbers in CWF 11100 = MSP/COB Contr. 6000 COB Contractor 11101 = MSP/COB Contr. 6010 Initial Enrollment Questionaire (IEQ) 11102 = MSP/COB Contr. 6020 IRS/SSA/CMS/Data Match. 11103 = MSP/COB Contr. 6030 HMO Rate Call 11104 = MSP/COB Contr. 6040 Litigation Settlement 11105 = MSP/COB Contr. 6050 Employer Voluntary Reporting 11106 = MSP/COB Contr. 6060 Insurer Voluntary Reporting 11107 = MSP/COB Contr. 6070 First Claim Development 11108 = MSP/COB Contr. 6080 Trauma Code Development 11109 = MSP/COB Contr. 6090 Secondary Claims Investigation 11110 = MSP/COB Contr. 7000 Self Reports 11111 = MSP/COB Contr. 7010 411.25 11112 = MSP/COB Contr. 7012 BCBS Voluntary Agreements 11113 = MSP/COB Contr. 7013 OPM Data Match (OPM) 11114 = MSP/COB Contr. 7014 State Workers' Compensation 11115 = MSP/COB Contr. 7015 WC Insurer Vol Data Sharing Agreement 11116 = MSP/COB Contr. 7016 Liabilty Ins Vol Data Sharing Agreement 11117 = MSP/COB Contr. 7017 Vol Data Sharing Agreement (No... 11118 = MSP/COB Contr. 7018 Pharmacy Benefit Manager Data 11119 = MSP/COB Contr. 7019 Workers' Compensation Medicare ... 11120 = MSP/COB Contr. 7020 To be determined 11121 = MSP/COB Contr. 7021 MIR Group Health Plan 11122 = MSP/COB Contr. 7022 MIR non-Group Health Plan 11123 = MSP/COB Contr. 7023 To be determined 11124 = MSP/COB Contr. 7024 To be determined 11125 = MSP/COB Contr. 7025 Recovery Audit Contractor - California 11126 = MSP/COB Contr. 7026 Recovery Audit Contractor - Florida 11127 = MSP/COB Contr. 7027 To be determined 11139 = MSP/COB Contr. 7039 Group Health PlanRecovery (eff. 01/01/2013) (CR7906) 11140 = MSP/COB Contr. 11141 = MSP/COB Contr. 7041 Non-Group Health Plan Non-ORM (eff. 01/01/2013) (CR7906) = MSP/COB Contr. 7041 COB/MSPRC (redefined (description) via CR7906) 11142 = MSP/COB Contr. 7042 Non-Group Health Plan Recovery (eff. 01/01/2013) (CR7906) 11143 = MSP/COB Contr. 7043 COBC/Medicare Part C/Medicare Advantage 11144 = MSP/COB Contr. 7044 To be determined 11199 = MSP/COB Contr. 7099 To be determined JURISDICTION 11 -- Part B MACs 11002 = J11 Roll-up 11202 = South Carolina - Palmetto Gov. Benefits Admin. (PGBA) 11302 = Virginia (eff.3/19/2011) Palmetto Gov. Benefits Admin. (PGBA) (replaces carrier #00904) 11402 = West Virginia (eff.6/18/2011) Palmetto Gov. Benefits Admin. (PGBA) 11502 = North Carolina (eff.5/28/2011) Palmetto Gov. Benefits Admin. (PGBA) JURISDICTION 12 -- Part B MACs 12002 = J12 Roll-up 12102 = Delaware (eff. 7/11/2008) (replaces carrier # 00902) 12202 = District of Columbia (eff. 7/11/2008) (replaces carrier # 00903) NOTE: Includes Montgomery & Prince Georges Counties in Maryland and Fairfax Counties and the City of Alexandria, VA 12302 = Maryland (eff. 7/11/2008) (replaces carrier # 00901) 12402 = New Jersey (eff. 11/14/2008) (replaces carrier # 00805) 12502 = Pennsylvania (eff. 12/12/2008) (replaces carrier # 00865) JURISDICTION 13 -- Part B MACs 13002 = J13 Roll-up 13102 = Connecticut (eff. 8/1/2008) (replaces carrier # 00591) 13202 = E. New York (eff. 7/18/2008) (replaces carrier # 00803) 13282 = W. New York (eff. 9/1/2008) (replaces carrier # 00801) 13292 = New York (Queens) (eff. 7/18/2008) (replaces carrier # 14330) JURISDICTION 14 -- Part B MACs 14002 = J14 Roll-up 14102 = Maine (eff. 6/1/2009) (replaces carrier # 31142) 14202 = Massachusetts (eff. 6/1/2009) (replaces carrier # 31143) 14302 = N. Hampshire (eff. 6/1/2009) (replaces carrier # 31144) 14402 = Rhode Island (eff. 5/1/2009) (replaces carrier # 00524) 14502 = Vermont (eff. 6/1/2009) (replaces carrier # 31145) 15002 = J15 Roll-up 15102 = Kentucky (eff. 4/30/2011) CGS Government Sservices 15202 = Ohio (eff. 06/15/2011) CGS Government Sservices Durable Medical Equipment (DME) MACs 16003 = National Heritage Insurance Company (NHIC) (A) (eff. 7/1/06) (replaces carrier #00811) 17003 = Administar Federal, Inc. (B) (eff. 7/1/06) (replaces carrier # 00635) 18003 = Connecticut General (CIGNA) (C) (eff. 06/2006) (replaces carrier #00885) 19003 = Noridan Mutual Ins. Co (D) (eff. 10/1/06) (replaces carrier #05655) 33333 = MSP/COB Contr, 4000 Litigation Settlement 44410 = STC Testing 55555 = MSP/COB Contr, 3000 HMO Rate Cell Adjustment 66001 = Noridian Competitive Acquisition Program 66666 = MSP/COB Contr. 77001 = Program Safeguard Contractor (PSC) (Mike Lopatin) 77002 = Program Safeguard Contractor (PSC) 77003 = Program Safeguard Contractor (PSC) 77004 = Program Safeguard Contractor (PSC) 77005 = Program Safeguard Contractor (PSC) 77006 = Program Safeguard Contractor (PSC) 77007 = Program Safeguard Contractor (PSC) 77008 = Program Safeguard Contractor (PSC) 77009 = Program Safeguard Contractor (PSC) 77010 = Program Safeguard Contractor (PSC) 77011 = Program Safeguard Contractor (PSC) 77012 = Program Safeguard Contractor (PSC) 77013 = Zone Program Integrity Contractor (ZPICs) (Tara Ross) 77014 = Zone Program Integrity Contractor (ZPICs) 77015 = Zone Program Integrity Contractor (ZPICs) 77016 = Zone Program Integrity Contractor (ZPICs) 77017 = Zone Program Integrity Contractor (ZPICs) 77018 = Zone Program Integrity Contractor (ZPICs) 77019 = Zone Program Integrity Contractor (ZPICs) 77020 = Zone Program Integrity Contractor (ZPICs) 77021 = Zone Program Integrity Contractor (ZPICs) 77022 = Zone Program Integrity Contractor (ZPICs) 77023 = Zone Program Integrity Contractor (ZPICs) 77024 = Zone Program Integrity Contractor (ZPICs) 77025 = Zone Program Integrity Contractor (ZPICs) 77026 = Zone Program Integrity Contractor (ZPICs) 77027 = Zone Program Integrity Contractor (ZPICs) 77028 = Zone Program Integrity Contractor (ZPICs) 77777 = MSP/COB Contr. 1000 IRS/SSA/HCFA Data Match 78001 = Medicare Drug Integrity Contractor (MEDIC) (Tara Ross) 78002 = MEDIC Contractor 78003 = MEDIC Contractor 78004 = MEDIC Contractor 78005 = MEDIC Contractor 78006 = MEDIC Contractor 78007 = MEDIC Contractor 78008 = MEDIC Contractor 78009 = MEDIC Contractor 78010 = MEDIC Contractor 78011 = MEDIC Contractor 78012 = MEDIC Contractor 78013 = MEDIC Contractor 78014 = MEDIC Contractor 78015 = MEDIC Contractor 79001 = MSP Recovery Contractor 88888 = MSP/COB Contr. 5000 Voluntary Agreements 99999 = MSP/COB Contr. 2000 Initial Questionaire Note: (CA) - 31140 & 31146 (MO) - 00523 & 00651 (NY) - 801 & 803 & 14330 Alaska-Oregon Aetna-Total (term. 09/2000) Arizona-Nevada Aetna-Total (term. 09/2000) Highmark-Total (term. 09/2000) MASSACHUSETTS BS-Total (term. 09/2000) MASSACHUSETTS BS TRI-STATE-Total (term. 09/2000) New Mexico-Oklahoma-Total (terminated) West.Consort.Occidental-Total (term. 09/2000) CLM_ADJ_RSN_TB Claim Adjustment Reason Code 1 = Deductible Amount Start: 01/01/1995 2 = Coinsurance Amount Start: 01/01/1995 3 = Co-payment Amount Start: 01/01/1995 4 = The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 5 = The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 6 = The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 7 = The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 8 = The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 9 = The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 10 = The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 11 = The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 Last Modified: 09/20/2009 12 = The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 13 = The date of death precedes the date of service. Start: 01/01/1995 14 = The date of birth follows the date of service. Start: 01/01/1995 15 = The authorization number is missing, invalid, or does not apply to the billed services or provider. Start: 01/01/1995 16 = Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 17 = Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 Stop: 07/01/2009 18 = Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/ service (Use only with Group Code OA) Start: 01/01/1995 19 = This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Start: 01/01/1995 20 = This injury/illness is covered by the liability carrier. Start: 01/01/1995 21 = This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 22 = This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 23 = The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) Start: 01/01/1995 24 = Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 25 = Payment denied. Your Stop loss deductible has not been met. Start: 01/01/1995 Stop: 04/01/2008 26 = Expenses incurred prior to coverage. Start: 01/01/1995 27 = Expenses incurred after coverage terminated Start: 01/01/1995 28 = Coverage not in effect at the time the service was provided. Start: 01/01/1995 Stop: 10/16/2003 Notes: Redundant to codes 26&27. 29 = The time limit for filing has expired. Start: 01/01/1995 30 = Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Start: 01/01/1995 Stop: 02/01/2006 31 = Patient cannot be identified as our insured Start: 01/01/1995 32 = Our records indicate that this dependent is not an eligible dependent as defined. Start: 01/01/1995 33 = Insured has no dependent coverage. Start: 01/01/1995 34 = Insured has no coverage for newborns. Start: 01/01/1995 35 = Lifetime benefit maximum has been reached. Start: 01/01/1995 36 = Balance does not exceed co-payment amount. Start: 01/01/1995 Stop: 10/16/2003 37 = Balance does not exceed deductible. Start: 01/01/1995 Stop: 10/16/2003 38 = Services not provided or authorized by designated (network/primary care) providers. Start: 01/01/1995 Stop: 01/01/2013 39 = Services denied at the time authorization/ pre-certification was requested. Start: 01/01/1995 40 = Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 41 = Discount agreed to in Preferred Provider contract. Start: 01/01/1995 Stop: 10/16/2003 42 = Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45) Start: 01/01/1995 Stop: 06/01/2007 43 = Gramm-Rudman reduction. Start: 01/01/1995 Stop: 07/01/2006 44 = Prompt-pay discount. Start: 01/01/1995 45 = Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). This change effective 7/1/2013: Charge exceeds fee schedule/maximum allowable or contracted/ legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability) Start: 01/01/1995 46 = This (these) service(s) is (are) not covered. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 96. 47 = This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Start: 01/01/1995 Stop: 02/01/2006 48 = This (these) procedure(s) is (are) not covered. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 96. 49 = These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 50 = These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 51 = These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 52 = The referring/prescribing/rendering provider is not eligible to refer/prescribe /order/perform the service billed. Start: 01/01/1995 Stop: 02/01/2006 53 = Services by an immediate relative or a member of the same household are not covered. Start: 01/01/1995 54 = Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 55 = Procedure/treatment is deemed experimental/ investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 56 = Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 57 = Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Start: 01/01/1995 Stop: 06/30/2007 Notes: Split into codes 150, 151, 152, 153 and 154. 58 = Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 59 = Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 60 = Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Start: 01/01/1995 61 = Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 62 = Payment denied/reduced for absence of, or exceeded, pre-certification/ authorization. Start: 01/01/1995 Stop: 04/01/2007 63 = Correction to a prior claim. Start: 01/01/1995 Stop: 10/16/2003 64 = Denial reversed per Medical Review. Start: 01/01/1995 Stop: 10/16/2003 65 = Procedure code was incorrect. This payment reflects the correct code. Start: 01/01/1995 Stop: 10/16/2003 66 = Blood Deductible. Start: 01/01/1995 67 = Lifetime reserve days. (Handled in QTY, QTY01=LA) Start: 01/01/1995 Stop: 10/16/2003 68 = DRG weight. (Handled in CLP12) Start: 01/01/1995 Stop: 10/16/2003 69 = Day outlier amount. Start: 01/01/1995 70 = Cost outlier - Adjustment to compensate for additional costs. Start: 01/01/1995 71 = Primary Payer amount. Start: 01/01/1995 Stop: 06/30/2000 Notes: Use code 23. 72 = Coinsurance day. (Handled in QTY, QTY01=CD) Start: 01/01/1995 Stop: 10/16/2003 73 = Administrative days. Start: 01/01/1995 Stop: 10/16/2003 74 = Indirect Medical Education Adjustment. Start: 01/01/1995 75 = Direct Medical Education Adjustment. Start: 01/01/1995 76 = Disproportionate Share Adjustment. Start: 01/01/1995 77 = Covered days. (Handled in QTY, QTY01=CA) Start: 01/01/1995 Stop: 10/16/2003 78 = Non-Covered days/Room charge adjustment. Start: 01/01/1995 79 = Cost Report days. (Handled in MIA15) Start: 01/01/1995 Stop: 10/16/2003 80 = Outlier days. (Handled in QTY, QTY01=OU) Start: 01/01/1995 Stop: 10/16/2003 81 = Discharges. Start: 01/01/1995 Stop: 10/16/2003 82 = PIP days. Start: 01/01/1995 Stop: 10/16/2003 83 = Total visits. Start: 01/01/1995 Stop: 10/16/2003 84 = Capital Adjustment. (Handled in MIA) Start: 01/01/1995 Stop: 10/16/2003 85 = Patient Interest Adjustment (Use Only Group code PR) Start: 01/01/1995 Notes: Only use when the payment of interest is the responsibility of the patient. 86 = Statutory Adjustment. Start: 01/01/1995 Stop: 10/16/2003 Notes: Duplicative of code 45. 87 = Transfer amount. Start: 01/01/1995 Stop: 01/01/2012 88 = Adjustment amount represents collection against receivable created in prior overpayment. Start: 01/01/1995 Stop: 06/30/2007 89 = Professional fees removed from charges. Start: 01/01/1995 90 = Ingredient cost adjustment. Note: To be used for pharmaceuticals only. Start: 01/01/1995 91 = Dispensing fee adjustment. Start: 01/01/1995 92 = Claim Paid in full. Start: 01/01/1995 Stop: 10/16/2003 93 = No Claim level Adjustments. Start: 01/01/1995 Stop: 10/16/2003 Notes: As of 004010, CAS at the claim level is optional. 94 = Processed in Excess of charges. Start: 01/01/1995 95 = Plan procedures not followed. Start: 01/01/1995 96 = Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 97 = The benefit for this service is included in the payment/allowance for another service/ procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 98 = The hospital must file the Medicare claim for this inpatient non-physician service. Start: 01/01/1995 Stop: 10/16/2003 99 = Medicare Secondary Payer Adjustment Amount. Start: 01/01/1995 Stop: 10/16/2003 100 = Payment made to patient/insured/responsible party/employer. Start: 01/01/1995 101 = Predetermination: anticipated payment upon completion of services or claim adjudication. Start: 01/01/1995 102 = Major Medical Adjustment. Start: 01/01/1995 103 = Provider promotional discount (e.g., Senior citizen discount). Start: 01/01/1995 104 = Managed care withholding. Start: 01/01/1995 105 = Tax withholding. Start: 01/01/1995 106 = Patient payment option/election not in effect. Start: 01/01/1995 107 = The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 108 = Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 109 = Claim/service not covered by this payer/ contractor. You must send the claim/service to the correct payer/contractor. Start: 01/01/1995 110 = Billing date predates service date. Start: 01/01/1995 111 = Not covered unless the provider accepts assignment. Start: 01/01/1995 112 = Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 113 = Payment denied because service/procedure was provided outside the United States or as a result of war. Start: 01/01/1995 Stop: 06/30/2007 Notes: Use Codes 157, 158 or 159. 114 = Procedure/product not approved by the Food and Drug Administration. Start: 01/01/1995 115 = Procedure postponed, canceled, or delayed. Start: 01/01/1995 116 = The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 117 = Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 118 = ESRD network support adjustment. Start: 01/01/1995 119 = Benefit maximum for this time period or occurrence has been reached. Start: 01/01/1995 120 = Patient is covered by a managed care plan. Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 24. 121 = Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 122 = Psychiatric reduction. Start: 01/01/1995 123 = Payer refund due to overpayment. Start: 01/01/1995 Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals. 124 = Payer refund amount - not our patient. Start: 01/01/1995 Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals. 125 = Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 126 = Deductible -- Major Medical Start: 02/28/1997 Stop: 04/01/2008 Notes: Use Group Code PR and code 1. 127 = Coinsurance -- Major Medical Start: 02/28/1997 Stop: 04/01/2008 Notes: Use Group Code PR and code 2. 128 = Newborn's services are covered in the mother's Allowance. Start: 02/28/1997 129 = Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 02/28/1997 130 = Claim submission fee. Start: 02/28/1997 131 = Claim specific negotiated discount. Start: 02/28/1997 132 = Prearranged demonstration project adjustment. Start: 02/28/1997 133 = The disposition of the claim/service is pending further review. This change effective 1/1/2013: The disposition of the claim/service is pending further review. (Use only with Group Code OA) Start: 02/28/1997 134 = Technical fees removed from charges. Start: 10/31/1998 135 = Interim bills cannot be processed. Start: 10/31/1998 136 = Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective 7/1/2013: Failure to follow prior payer's coverage rules. (Use only with Group Code OA) Start: 10/31/1998 137 = Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 138 = Appeal procedures not followed or time limits not met. Start: 06/30/1999 139 = Contracted funding agreement - Subscriber is employed by the provider of services. Start: 06/30/1999 140 = Patient/Insured health identification number and name do not match. Start: 06/30/1999 141 = Claim spans eligible and ineligible periods of coverage. Start: 06/30/1999 Stop: 07/01/2012 142 = Monthly Medicaid patient liability amount. Start: 06/30/2000 143 = Portion of payment deferred. Start: 02/28/2001 144 = Incentive adjustment, e.g. preferred product/service. Start: 06/30/2001 145 = Premium payment withholding Start: 06/30/2002 Stop: 04/01/2008 Notes: Use Group Code CO and code 45. 146 = Diagnosis was invalid for the date(s) of service reported. Start: 06/30/2002 147 = Provider contracted/negotiated rate expired or not on file. Start: 06/30/2002 148 = Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 06/30/2002 149 = Lifetime benefit maximum has been reached for this service/benefit category. Start: 10/31/2002 150 = Payer deems the information submitted does not support this level of service. Start: 10/31/2002 151 = Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Start: 10/31/2002 152 = Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 10/31/2002 153 = Payer deems the information submitted does not support this dosage. Start: 10/31/2002 154 = Payer deems the information submitted does not support this day's supply. Start: 10/31/2002 155 = Patient refused the service/procedure. Start: 06/30/2003 156 = Flexible spending account payments. Note: Use code 187. Start: 09/30/2003 Stop: 10/01/2009 157 = Service/procedure was provided as a result of an act of war. Start: 09/30/2003 158 = Service/procedure was provided outside of the United States. Start: 09/30/2003 159 = Service/procedure was provided as a result of terrorism. Start: 09/30/2003 160 = Injury/illness was the result of an activity that is a benefit exclusion. Start: 09/30/2003 161 = Provider performance bonus Start: 02/29/2004 162 = State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Start: 02/29/2004 163 = Attachment referenced on the claim was not received. Start: 06/30/2004 164 = Attachment referenced on the claim was not received in a timely fashion. Start: 06/30/2004 165 = Referral absent or exceeded. Start: 10/31/2004 166 = These services were submitted after this payers responsibility for processing claims under this plan ended. Start: 02/28/2005 167 = This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Payment Information REF), if present. Start: 06/30/2005 168 = Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. Start: 06/30/2005 169 = Alternate benefit has been provided. Start: 06/30/2005 170 = Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 171 = Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 172 = Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 173 = Service was not prescribed by a physician. This change effective 7/1/2013: Service/ equipment was not prescribed by a physician. Start: 06/30/2005 174 = Service was not prescribed prior to delivery. Start: 06/30/2005 175 = Prescription is incomplete. Start: 06/30/2005 176 = Prescription is not current. Start: 06/30/2005 177 = Patient has not met the required eligibility requirements. Start: 06/30/2005 178 = Patient has not met the required spend down requirements. Start: 06/30/2005 179 = Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) , if present. Start: 06/30/2005 180 = Patient has not met the required residency requirements. Start: 06/30/2005 181 = Procedure code was invalid on the date of service. Start: 06/30/2005 182 = Procedure modifier was invalid on the date of service. Start: 06/30/2005 183 = The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 184 = The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 185 = The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 Last Modified: 09/20/2009 186 = Level of care change adjustment. Start: 06/30/2005 187 = Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) Start: 06/30/2005 188 = This product/procedure is only covered when used according to FDA recommendations. Start: 06/30/2005 189 = 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service Start: 06/30/2005 190 = Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Start: 10/31/2005 191 = Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) Start: 10/31/2005 192 = Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. Start: 10/31/2005 193 = Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. Start: 02/28/2006 194 = Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Start: 02/28/2006 195 = Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 196 = Claim/service denied based on prior payer's coverage determination. Start: 06/30/2006 Stop: 02/01/2007 Notes: Use code 136. 197 = Precertification/authorization/notification absent. Start: 10/31/2006 198 = Precertification/authorization exceeded. Start: 10/31/2006 199 = Revenue code and Procedure code do not match. Start: 10/31/2006 200 = Expenses incurred during lapse in coverage Start: 10/31/2006 201 = Workers' Compensation case settled. Patient is responsible for amount of this claim/ service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR). This change effective 7/1/2013: Workers Compensation case settled. Patient is responsible for amount of this claim/ service through WC 'Medicare set aside arrangement' or other agreement. (Use only with Group Code PR) Start: 10/31/2006 202 = Non-covered personal comfort or convenience services. Start: 02/28/2007 203 = Discontinued or reduced service. Start: 02/28/2007 204 = This service/equipment/drug is not covered under the patient's current benefit plan Start: 02/28/2007 205 = Pharmacy discount card processing fee Start: 07/09/2007 206 = National Provider Identifier - missing. Start: 07/09/2007 207 = National Provider identifier - Invalid format Start: 07/09/2007 208 = National Provider Identifier - Not matched. Start: 07/09/2007 209 = Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. The provider. cannot collect this amount from the patient However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA) Start: 07/09/2007 210 = Payment adjusted because pre-certification/ authorization not received in a timely fashion Start: 07/09/2007 211 = National Drug Codes (NDC) not eligible for rebate, are not covered. Start: 07/09/2007 212 = Administrative surcharges are not covered Start: 11/05/2007 213 = Non-compliance with the physician self referral prohibition legislation or payer policy. Start: 01/27/2008 214 = Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only Start: 01/27/2008 215 = Based on subrogation of a third party settlement Start: 01/27/2008 216 = Based on the findings of a review organization Start: 01/27/2008 217 = Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only) Start: 01/27/2008 218 = Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) To be used for Workers' Compensation only Start: 01/27/2008 219 = Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Start: 01/27/2008 220 = The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only) Start: 01/27/2008 221 = Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This change effective 7/1/2013: Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only) Start: 01/27/2008 222 = Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/01/2008 223 = Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Start: 06/01/2008 224 = Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Start: 06/01/2008 225 = Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) Start: 06/01/2008 226 = Information requested from the Billing/ Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) This change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/ incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 227 = Information requested from the patient/ insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 228 = Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication Start: 09/21/2008 229 = Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. Use Group Code PR. This change effective 7/1/2013: Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR) Start: 01/25/2009 230 = No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty. Start: 01/25/2009 231 = Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2009 232 = Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Start: 11/01/2009 233 = Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Start: 01/24/2010 234 = This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/24/2010 235 = Sales Tax Start: 06/06/2010 236 = This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Start: 01/30/2011 237 = Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 06/05/2011 238 = Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). This change effective 7/1/2013: Claim spans eligible and ineligible periods of coverage , this is the reduction for the ineligible period. (Use only with Group Code PR) Start: 03/01/2012 239 = Claim spans eligible and ineligible periods of coverage. Rebill separate claims. Start: 03/01/2012 240 = The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/03/2012 241 = Low Income Subsidy (LIS) Co-payment Amount Start: 06/03/2012 242 = Services not provided by network/primary care providers. Start: 06/03/2012 243 = Services not authorized by network/primary care providers. Start: 06/03/2012 244 = Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only. Start: 09/30/2012 245 = Provider performance program withhold. Start: 09/30/2012 246 = This non-payable code is for required reporting only. Start: 09/30/2012 247 = Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). 248 = Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). 249 = This claim has been identified as a readmission. (Use only with Group Code CO) Start: 09/30/2012 250 = The attachment content received is inconsistent with the expected content. Start: 09/30/2012 251 = The attachment content received did not contain the content required to process this claim or service. Start: 09/30/2012 252 = An attachment is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Start: 09/30/2012 A0 = Patient refund amount. Start: 01/01/1995 A1 = Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 A2 = Contractual adjustment. Start: 01/01/1995 Stop: 01/01/2008 Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code. A3 = Medicare Secondary Payer liability met. Start: 01/01/1995 Stop: 10/16/2003 A4 = Medicare Claim PPS Capital Day Outlier Amount. Start: 01/01/1995 Stop: 04/01/2008 A5 = Medicare Claim PPS Capital Cost Outlier Amount. Start: 01/01/1995 A6 = Prior hospitalization or 30 day transfer requirement not met. Start: 01/01/1995 A7 = Presumptive Payment Adjustment Start: 01/01/1995 A8 = Ungroupable DRG. Start: 01/01/1995 B1 = Non-covered visits. Start: 01/01/1995 B2 = Covered visits. Start: 01/01/1995 Stop: 10/16/2003 B3 = Covered charges. Start: 01/01/1995 Stop: 10/16/2003 B4 = Late filing penalty. Start: 01/01/1995 B5 = Coverage/program guidelines were not met or were exceeded. Start: 01/01/1995 B6 = This payment is adjusted when performed/ billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Start: 01/01/1995 Stop: 02/01/2006 B7 = This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 B8 = Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 B9 = Patient is enrolled in a Hospice. Start: 01/01/1995 B10 = Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Start: 01/01/1995 B11 = The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/ processor. Start: 01/01/1995 B12 = Services not documented in patients' medical records. Start: 01/01/1995 B13 = Previously paid. Payment for this claim/ service may have been provided in a previous payment. Start: 01/01/1995 B14 = Only one visit or consultation per physician per day is covered. Start: 01/01/1995 B15 = This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/ procedure has not been received/adjudicated . Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 B16 = 'New Patient' qualifications were not met. Start: 01/01/1995 B17 = Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. Start: 01/01/1995 Stop: 02/01/2006 B18 = This procedure code and modifier were invalid on the date of service. Start: 01/01/1995 Stop: 03/01/2009 B19 = Claim/service adjusted because of the finding of a Review Organization. Start: 01/01/1995 Stop: 10/16/2003 B20 = Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 B21 = The charges were reduced because the service/care was partially furnished by another physician. Start: 01/01/1995 Stop: 10/16/2003 B22 = This payment is adjusted based on the diagnosis. Start: 01/01/1995 B23 = Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 D1 = Claim/service denied. Level of subluxation is missing or inadequate. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D2 = Claim lacks the name, strength, or dosage of the drug furnished. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D3 = Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D4 = Claim/service does not indicate the period of time for which this will be needed. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D5 = Claim/service denied. Claim lacks individual lab codes included in the test. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D6 = Claim/service denied. Claim did not include patient's medical record for the service. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D7 = Claim/service denied. Claim lacks date of patient's most recent physician visit. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D8 = Claim/service denied. Claim lacks indicator that 'x-ray is available for review.' Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D9 = Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary. D10 = Claim/service denied. Completed physician financial relationship form not on file. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D11 = Claim lacks completed pacemaker registration form. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D12 = Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D13 = Claim/service denied. Performed by a facility/supplier in which the ordering/ referring physician has a financial interest. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D14 = Claim lacks indication that plan of treatment is on file. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D15 = Claim lacks indication that service was supervised or evaluated by a physician. Start: 01/01/1995 Stop: 10/16/2003 Notes: Use code 17. D16 = Claim lacks prior payer payment information Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code âN4ã. D17 = Claim/Service has invalid non-covered days. Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code. D18 = Claim/Service has missing diagnosis information. Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code. D19 = Claim/Service lacks Physician/Operative or other supporting documentation Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code. D20 = Claim/Service missing service/product information. Start: 01/01/1995 Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code. D21 = This (these) diagnosis(es) is (are) missing or are invalid Start: 01/01/1995 Stop: 06/30/2007 D22 = Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for time frame only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code Start: 01/27/2008 Stop: 01/01/2009 D23 = This dual eligible patient is covered by Medicare Part D per Medicare Retro- Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 11/01/2009 Stop: 01/01/2012 W1 = Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Start: 02/29/2000 W2 = Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only. Start: 10/17/2010 W3 = The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only. Start: 09/30/2012 W4 = Workers' Compensation Medical Treatment Guideline Adjustment. Start: 09/30/2012 Y1 = Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only. Start: 09/30/2012 Y2 = Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only. Start: 09/30/2012 Y3 = Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only. Start: 09/30/2012 CLM_BENE_ID_TYPE_TB Claim Beneficiary Identifier Type Table M = MBI H = HICN CLM_CARE_IMPRVMT_MODEL_TB Claim Care Improvement Model Table 61 = CLAIM CARE IMPROVEMENT MODEL 1 62 = CLAIM CARE IMPROVEMENT MODEL 2 63 = CLAIM CARE IMPROVEMENT MODEL 3 64 = CLAIM CARE IMPROVEMENT MODEL 4 CLM_DGNS_VRSN_TB Claim Diagnosis Version Code Table Valid Values: 9 = ICD-9 0 = ICD-10 CLM_DISP_TB Claim Disposition Table 01 = Debit accepted 02 = Debit accepted (automatic adjustment) applicable through 4/4/93 03 = Cancel accepted 61 = *Conversion code: debit accepted 62 = *Conversion code: debit accepted (automatic adjustment) 63 = *Conversion code: cancel accepted *Used only during conversion period: 1/1/91 - 2/21/91 CLM_EXCPTD_NEXCPTD_TRTMT_TB Claim Excepted/Nonexcepted Treatment Table 0 = No Entry 1 = Excepted 2 = Nonexcepted CLM_FPS_MSN_CD_TB Claim FPS MSN Code Table Section 1 Ambulance 1.1 = Payment for transportation is allowed only to the closest facility that can provide the necessary care. 1.10 = Air ambulance is not covered since you were not taken to the airport by ambulance. 1.11 = The information provided does not support the need for an air ambulance. The approved amount is based on ground ambulance. 1.2 = Payment is denied because the ambulance company is not approved by Medicare. 1.3 = Ambulance service to a funeral home is not covered. 1.4 = Transportation in a vehicle other than an ambulance is not covered. 1.5 = Transportation to a facility to be closer to home or family is not covered. 1.6 = This service is included in the allowance for the ambulance transportation. 1.7 = Ambulance services to or from a doctor's office are not covered. 1.8 = This service is denied because you refused to be transported. 1.9 = Payment for ambulance services does not include mileage when you were not in the ambulance. Section 10 Foot Care 10.1 = Shoes are only covered as part of a leg brace. Section 11 Transfer of Claims or Parts of Claims 11.1 = Your claim has been forwarded to the correct Medicare contractor for processing. You will receive a notice from them. 11.10 = We have identified you as a Railroad Retirement Board (RRB) Medicare beneficiary. You must send your claim for these services for processing to the RRB carrier Palmetto GBA, at PO Box 10066, Augusta, GA 30999. 11.11 = This claim/service is not payable under our claims jurisdiction. We have notified your provider to send your claim for these services to the United Mine Workers of America for processing. 11.2 = This information is being sent to Medicaid. They will review it to see if additional benefits can be paid. 11.3 = Our records show that you are enrolled in a Medicare health plan. Your provider must bill this service to the plan. 11.4 = Our records show that you are enrolled in a Medicare health plan. Your claim was sent to the plan for processing. 11.5 = This claim will need to be submitted to (another carrier, a Durable Medical Equipment Medicare Administrative Contractor (DME MAC), or Medicaid agency) 11.6 = We have asked your provider to submit this claim to the proper Medicare Administrative Contractor (MAC). That MAC is (name and address). NOTE: Due to different systems' capabilities, DMACs may omit the final sentence in this message, "That MAC is (name and address)," whenever this message is used. Part A and Part B MACs are expected to use the complete message. This instruction also applies to the Spanish translation of the message. 11.7 = This claim/service is not payable under our claims jurisdiction area. We have notified your provider that they must forward the claim/service to the correct carrier for processing. 11.8 = This claim will need to be submitted to the Region B Durable Medical Equipment Regional Carrier. 11.9 = This claim/service is not payable under our claims jurisdiction. We have notified your provider to send your claim for these services to the Railroad Retirement Board Medicare carrier. Section 12 Hearing Aids 12.1 = Hearing aids are not covered. Section 13 Skilled Nursing Facility 13.1 = No qualifying hospital stay dates were shown for this skilled nursing facility stay. 13.10 = Medicare Part B doesn't pay for items or services provided by this type of healthcare provider since our records show that you were receiving Medicare Part A benefits in a skilled nursing facility on this date. 13.11 = You have ___ days(s) remaining of your total 100 days of skilled nursing facility benefits for this benefit period 13.12 = Medicare Part B doesn't pay separately for this item/service. Payment for this item/service should be included in another Medicare benefit. The hospital/ nursing facility must bill for this Medicare service. 13.2 = Skilled nursing facility benefits are only available after a hospital stay of at least 3 days. 13.3 = Information provided does not support the need for skilled nursing facility care. 13.4 = Information provided does not support the need for continued care in a skilled nursing facility. 13.5 = You were not admitted to the skilled nursing facility within 30 days of your hospital discharge. 13.6 = Rural primary care skilled nursing facility benefits are only available after a hospital stay of at least 2 days. 13.7 = Normally, care is not covered when provided in a bed that is not certified by Medicare. However, since you received covered care, we have decided that you will not have to pay the facility for anything more than Medicare coinsurance and noncovered items. 13.8 = The skilled nursing facility should file a claim for Medicare benefits because you were an inpatient. 13.9 = Medicare Part B does not pay for this item or service since our records show that you were in a skilled nursing facility on this date. Section 14 Laboratory 14.1 = The laboratory is not approved for this type of test. 14.10 = Medicare does not allow a separate payment for EKG readings. 14.11 = A travel allowance is paid only when a covered specimen collection fee is billed 14.12 = Payment for transportation can only be made if an X-ray or EKG is performed. 14.13 = The laboratory was not approved for this test on the date it was performed. 14.2 = Medicare approved less for this individual test because it can be done as part of a complete group of tests. 14.3 = Services or items not approved by the Food and Drug Administration are not covered. 14.4 = Payment denied because the claim did not show who performed the test and/or the amount charged. 14.5 = Payment denied because the claim did not show if the test was purchased by the physician or if the physician performed the test. 14.6 = This test must be billed by the laboratory that did the work. 14.7 = This service is paid at 100% of the Medicare approved amount. 14.8 = Payment cannot be made because the physician has a financial relationship with the laboratory. 14.9 = Medicare cannot pay for this service for the diagnosis shown on the claim. Section Medical Necessity 15.1 = The information provided does not support the need for this many services or items. 15.10 = Medicare does not pay for more than one assistant surgeon for this procedure. 15.11 = Medicare does not pay for an assistant surgeon for this procedure/surgery. 15.12 = Medicare does not pay for two surgeons for this procedure. 15.13 = Medicare does not pay for team surgeons for this procedure. 15.14 = Medicare does not pay for acupuncture. 15.15 = Payment has been reduced because information provided does not support the need for this item as billed. 15.16 = Your claim was reviewed by our medical staff. 15.17 = We have approved this service at a reduced level. 15.18 = Medicare does not cover this service at home. 15.19 = Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD. 15.2 = The information provided does not support the need for this equipment. 15.20 = The following policies were used when we made this decision: _____ 15.21 = The information provided does not support the need for this many services or items in this period of time but you do not have to pay this amount. 15.22 = The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service. 15.3 = The information provided does not support the need for the special features of this equipment. 15.4 = The information provided does not support the need for this service or item. 15.5 = The information provided does not support the need for similar services by more than one doctor during the same time period. 15.6 = The information provided does not support the need for this many services or items within this period of time. 15.7 = The information provided does not support the need for more than one visit a day. 15.8 = The information provided does not support the level of service as shown on the claim. 15.9 = The Quality Improvement Organization did not approve this service. 15.96 = Medicare does not pay for this investigational device(s). 15.97 = Medicare cannot pay for this investigational device because the approved period for the investigational device in the FDA clinical trial has not begun. 15.98 = Medicare cannot pay for this investigational device because the approved period for the investigational device in the FDA clinical trial has expired. 15.99 = Medicare does not pay for this many services on the same day. You cannot be billed for this service. Section 16 Miscellaneous 16.1 = The service cannot be approved because the date on the claim shows it was billed before it was provided. 16.10 = Medicare does not pay for this item or service. 16.11 = Payment was reduced for late filing. You cannot be billed for the reduction. 16.12 = Outpatient mental health services are paid at 50% of the approved charges. 16.13 = The code(s) your provider used is/are not valid for the date of service billed. 16.14 = The attached check replaces your previous check (#____) dated (______). 16.15 = The attached check replaces your previous check. 16.16 = As requested, this is a duplicate copy of your Medicare Summary Notice. See "Message Expiration Date" and "Message Notes" columns -------> 16.17 = Medicare only pays for these services if you get them with total parenteral nutrition. 16.18 = Medicare won't pay for services provided before certified parenteral/enteral nutrition therapy started. 16.19 = The amount Medicare pays for a parenteral/enteral nutrition supply is based on the level of care you need (based on your diagnosis). 16.2 = This service cannot be paid when provided in this location/facility. 16.20 = The approved payment for calories/grams is the most Medicare may allow for the diagnosis stated. 16.21 = The procedure code was changed to reflect the actual service rendered. 16.22 = Medicare does not pay for services when no charge is indicated. 16.23 = This check is for the amount you overpaid 16.24 = Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, the service must be provided by a doctor licensed to practice in the United States. 16.25 = Medicare does not pay for this much equipment, or this many services or supplies. 16.26 = Medicare does not pay for services or items related to a procedure that has not been approved or billed. 16.27 = This service is not covered since our records show you were in the hospital at this time. 16.28 = Medicare does not pay for services or equipment that you have not received. 16.29 = Payment is included in another service you have received. 16.3 = The claim did not show that this service or item was prescribed by your doctor. 16.30 = Services billed separately on this claim have been combined under this procedure. 16.31 = You are responsible to pay the primary physician care the agreed monthly charge. 16.32 = Medicare does not pay separately for this service. 16.33 = Your payment includes interest because Medicare exceeded processing time limits. 16.34 = You should not be billed for this service . You are only responsible for any deductible and coinsurance amounts listed in the "You May Be Billed" column. This message should be revised to read "Maximum You May Be Billed" (in place of "You May Be Billed") when your MAC implements the new MSN design. See "Message Implementation Date" and "Message Notes." 16.35 = You do not have to pay this amount. 16.36 = If you have already paid it, you are entitled to a refund from this provider. 16.37 = Please see the back of this notice. See "Message Expiration Date" and "Message Notes" columns 16.38 = Charges are not incurred for leave of absence days. 16.39 = Only one provider can be paid for this service per calendar month. Payment has already been made to another provider for this service. 16.4 = This service requires prior approval by the Quality Improvement Organization. 16.40 = Only one inpatient service per day is allowed. 16.41 = Payment is being denied because you refused to request reimbursement under your Medicare benefits. 16.42 = The provider's determination of noncoverage is correct. 16.43 = This service cannot be approved without a treatment plan and supervision of a doctor. 16.44 = Routine care is not covered. 16.45 = You cannot be billed separately for this item or service. You do not have to pay this amount. 16.46 = Medicare payment limits do not affect a Native American's right to free care at Indian Health Institutions. 16.47 = When deductible is applied to outpatient psychiatric services, you may be billed for up to the approved amount. The "You May Be Billed" column will tell you the correct amount to pay your provider. This message should be revised to read "Maximum You May Be Billed" (in place of "You May Be Billed" when your MAC implements the new MSN design. 16.48 = Medicare does not pay for this item or service for this condition. 16.49 = This claim/service is not covered because alternative services were available, and should have been utilized. 16.5 = This service cannot be approved without a treatment plan by a physical or occupational therapist. 16.50 = The doctor or supplier may not bill more than the Medicare allowed amount. 16.51 = This service is not covered prior to July 1, 2001. 16.52 = This service was denied because coverage for this service is provided only after a documented failed trial of pelvic muscle exercise training. 16.53 = The amount Medicare paid the provider for this claim is ($______). 16.54 = This service is not covered prior to January 1, 2002. 16.55 = The provider billed this charge as non-covered. 16.56 = Claim denied because information from the Social Security Administration indicates that you have been deported. 16.57 = Medicare Part B does not pay for this item or service since our records show that you were in a Medicare health plan on this date. Your provider must bill this service to the Medicare health plan. 16.58 = The provider billed this charge as non-covered. You do not have to pay this amount. 16.59 = Medicare doesn't pay for missed appointments. 16.6 = This item or service cannot be paid unless the provider accepts assignment. 16.60 = Want to see your MSN right away? Access your Original Medicare claims directly at www.MyMedicare.gov, usually within 24 hours after Medicare processes the claim. You can also order duplicate MSNs, track your preventive services, and print an "On the Go" report to share with your provider. 16.61 = Outpatient mental health services are paid at 55% of the approved amount. 16.62 = Outpatient mental health services are paid at 60% of the approved amount 16.63 = Outpatient mental health services are paid at 65% of the approved amount. 16.64 = IMPORTANT: Starting in March 2010, Medicare will begin to mail Part A and Part B MSNs in the same envelope when possible. 16.66 = Medicare doesn't pay for DMEPOS items or services when provided by a hospital or physician if there is no matching date of discharge or date of service. 16.67 = Medicare doesn't pay for services or items when provided by a hospital when there is no matching date of discharge. 16.7 = Your provider must complete and submit your claim. 16.71 = Your provider must complete and submit your claim. 16.72 = This claim was denied because it was Submitted with a non-affirmative prior authorization request. 16.73 = This claim has received a payment reduction because it did not first go through the prior authorization process. 16.74 = This claim is denied because there is no record of a prior authorization request to support this record. 16.76 = This service/item was not covered because you have exceeded the lifetime limit for getting this service/item. 16.77 = This service/item was not covered because it was not provided as part of a qualifying trial/study. 16.8 = Payment is included in another service received on the same day. 16.9 = This allowance has been reduced by the amount previously paid for a related procedure. 16.98 = The amount you paid to the provider for this claim was more than the required payment. You should be receiving a refund of $______ from your provider, which is the difference between what you paid and what you should have paid. 16.99 = The amount owed you is $________. Medicare no longer routinely issues payment under $1 This amount due will be included on a future check issued to you. If you want this money issued immediately , please contact us at the address and phone number shown at the bottom of this page. Section 17 Non Physician Services 17.1 = Services performed by a private duty nurse are not covered. 17.10 = The allowance has been reduced because the anesthesiologist medically directed concurrent procedures. 17.11 = This item or service cannot be paid as billed. 17.12 = This service is not covered when provided by an independent therapist. 17.13 = Each year, Medicare pays for a limited amount of physical therapy and speech- language pathology services and a separate amount of occupational therapy services. Medically necessary therapy over these limits is covered when approved by Medicare. 17.14 = Charges for maintenance therapy are not covered. 17.15 = This service cannot be paid unless certified by your physician every (___) days. 17.16 = The hospital should file a claim for Medicare benefits because these services were performed in a hospital setting. 17.17 = Medicare already paid for an initial visit for this service with this physician, another physician in his group practice, or a provider. Your doctor or provider must use a different code to bill for subsequent visits. 17.18 = ($) has been applied during this calendar year (CCYY) towards the ($) limit on outpatient physical therapy and speech- language pathology benefits. 17.19 = ($) has been applied during this calendar year (CCYY) towards the ($) limit on outpatient occupational therapy benefits. 17.2 = This anesthesia service must be billed by a doctor. 17.21 = The items or service was denied because Medicare can't pay for services ordered by or referred by this provider at this time" for this message number. 17.25 = Medicare does not pay for services of a nurse practitioner/clinical nurse specialist for this place and/or date of service. 17.3 = This service was denied because you did not receive it under the direct supervision of a doctor. 17.33 = Medicare does not pay for services by a noncertified nonphysician practitioner. 17.4 = Services performed by an audiologist are not covered except for diagnostic procedures. 17.5 = Your provider's employer must file this claim and agree to accept assignment. 17.6 = Full payment was not made for this service(s) because the yearly limit has been met. 17.7 = This service must be performed by a licensed clinical social worker. 17.8 = Payment was denied because the maximum benefit allowance has been reached. 17.9 = Medicare (Part A/Part B) pays for this service. The provider must bill the correct Medicare contractor. Section 18 Preventive Care 18.1 = Routine examinations and related services aren't covered. 18.10 = Expired 18.11 = Expired 18.12 = Screening mammograms are covered annually for women 40 years of age and older. 18.13 = This service isn't covered for people under 50 years old. 18.14 = Service is being denied because it has not been (12/24/48) months since your last (test/procedure) of this kind. 18.15 = Medicare only covers this procedure for people considered to be at high risk for colorectal cancer. 18.16 = This service is being denied because payment has already been made for a similar procedure within a set time frame 18.17 = Medicare pays for a screening Pap test and a screening pelvic examination once every 2 years unless high risk factors are present. 18.18 = Medicare does not pay for this service separately since payment of it is included in our allowance for other services you received on the same day. 18.19 = This service isn't covered until after your 50th birthday. 18.2 = This immunization and/or preventive care is not covered. 18.20 = Expired 18.21 = 18.22 = This service was denied because Medicare only allows the Welcome to Medicare preventive visit within the first 12 months you have Part B coverage. 18.23 = You pay 25% of the Medicare-approved amount for this service. 18.24 = This service was denied. Medicare doesn't cover an Annual Wellness Visit within the first 12 months of your Medicare Part B coverage. Medicare does cover a one-time Welcome to Medicare preventive visit with in the first 12 months. 18.25 = Your Annual Wellness Visit has been approved. You will qualify for another Annual Wellness Visit 12 months after the date of this visit. 18.26 = This service was denied because it occurred too soon after your last covered Annual Wellness Visit. Medicare only covers one Annual Wellness Visit within a 12 month period. 18.27 = This service was denied because it occurred too soon after your Initial Preventive Physical Exam. 18.3 = Screening mammography is not covered for women under 35 years of age. 18.4 = This service is being denied because it has not been (__) months since your last examination of this kind. 18.5 = Medicare will pay for another screening mammogram in 12 months. 18.6 = A screening mammography is covered only once for women age 35 - 39. 18.7 = Screening pap tests are covered only once every 24 months unless high risk factors are present. 18.8 = Deleted during EOMB-MSN transition. 18.9 = Deleted during EOMB-MSN transition. 18.94 = Medicare pays for screening Pap smear and/or screening pelvic examination (including a clinical breast examination) only once every 2 years unless high risk factors are present. Section 19 Hospital Based Physician Services 19.1 = Services of a hospital-based specialist are not covered unless there is an agreement between the hospital and the specialist. 19.2 = Payment was reduced because this service was performed in a hospital outpatient setting rather than a provider's office. 19.3 = Only one hospital visit or consultation per provider is allowed per day. Section 2 Blood 2.1 = The first three pints of blood used in each year are not covered. 2.2 = Charges for replaced blood are not covered Section 20 Benefit Limits 20.1 = You have used all of your benefit days for this period. 20.10 = This service was denied because Medicare only pays up to 10 hours of diabetes education training during the initial 12-month period. Our records show you have already obtained 10 hours of training. 20.11 = This service was denied because Medicare pays for two hours of follow-up diabetes education training during a calendar year . Our records show you have already obtained two hours of training for this calendar year. 20.12 = This service was denied because Medicare only covers this service once a lifetime. 20.13 = This service was denied because Medicare only pays up to three hours of medical nutrition therapy during a calendar year. Our records show you have already received three hours of medical nutrition therapy. 20.14 = This service was denied because Medicare only pays two hours of follow-up for medical nutrition therapy during a calendar year. Our records show you have already received two hours of follow-up services for this calendar year. 20.2 = You have reached your limit of 190 days of psychiatric hospital services. 20.3 = You have reached your limit of 60 lifetime reserve days. 20.4 = (__) of the Benefit Days Used were charged to your Lifetime Reserve Day benefit. 20.5 = These services cannot be paid because your benefits are exhausted at this time. 20.6 = Days used has been reduced by the primary group insurer's payment. 20.7 = You have (___) day(s) remaining of your 190-day psychiatric limit. 20.8 = Days are being subtracted from your total inpatient hospital benefits for this benefit period. 20.9 = Services after (mm/dd/yy) cannot be paid because your benefits were exhausted. 20.91 = This service was denied. Medicare covers a one-time initial preventative physical exam (Welcome to Medicare physical exam) if you get it within the first 12 months of the effective date of your Medicare Part B coverage. Section 21 Restrictions to Coverage 21.1 = Services performed by an immediate relative or a member of the same household are not covered. 21.10 = A surgical assistant is not covered for this place and/or date of service. 21.11 = This service was not covered by Medicare at the time you received it. 21.12 = This hospital service was not covered because the attending physician was not eligible to receive Medicare benefits at the time the service was performed. 21.13 = This surgery was not covered because the attending physician was not eligible to receive Medicare benefits at the time the service was performed. 21.14 = Medicare cannot pay for this investigational device because the FDA clinical trial period has not begun. 21.15 = Medicare cannot pay for this investigational device because the FDA clinical trial period has ended. 21.16 = Medicare does not pay for this investigational device. 21.17 = Your provider submitted noncovered charges. You are responsible for paying these charges. 21.18 = This item or service is not covered when performed or ordered by this provider. 21.19 = This provider decided to dropout of Medicare. No payment can be made for this service. You are responsible for this charge. Under Federal law, your doctor cannot charge you more than the limiting charge amount. 21.2 = The provider of this service is not eligible to receive Medicare payments. 21.20 = This provider decided to dropout of Medicare. No payment can be made for this service. You are responsible for this charge. 21.21 = This service was denied because Medicare only covers this service under certain circumstances. 21.22 = Medicare does not pay for this service because it is considered investigational and/or experimental in these circumstances. 21.23 = Your claim is being denied because the physician noted on the claim has been deceased for more than 15 months. 21.24 = This service is not covered for patients over age 60. 21.25 = This service was denied because Medicare only covers this service in certain settings. 21.26 = Claim denied because services were provided by an Opt-Out physician or practitioner. No Medicare payment may be made. 21.27 = Services provided by a Medicare sanctioned/excluded provider. No Medicare payment may be made. 21.3 = This provider was not covered by Medicare when you received this service. 21.30 = The provider decided to drop out of Medicare. No payment can be made for this service. You are responsible for this charge. 21.31 = This service was not covered by Medicare at the time you recieved it. 21.32 = This service was denied because Medicare only covers this service under certain circumstances. 21.4 = Services provided outside the United States are not covered. See your Medicare Handbook for services received in Canada and Mexico. 21.5 = Services needed as a result of war are not covered. 21.6 = This item or service is not covered when performed, referred or ordered by this provider. 21.7 = This service should be included on your inpatient bill. 21.8 = Services performed using equipment that has not been approved by the Food and Drug Administration are not covered. 21.9 = Payment cannot be made for unauthorized service outside the managed care plan. Section 22 Split Claims 22.1 = Your claim was separated for processing. The remaining services may appear on a separate notice. Section 23 Surgery 23.1 = The cost of care before and after the surgery or procedure is included in the approved amount for that service. 23.10 = Payment has been reduced because this procedure was terminated before anesthesia was started. 23.11 = Payment cannot be made because the surgery was canceled or postponed. 23.12 = Payment has been reduced because the surgery was canceled after you were prepared for surgery. 23.13 = Because you were prepared for surgery and anesthesia was started, full payment is being made even though the surgery was canceled. 23.14 = The assistant surgeon must file a separate claim for this service. 23.15 = The approved amount is less because the payment is divided between two doctors. 23.16 = An additional amount is not allowed for this service when it is performed on both the left and right sides of the body. 23.17 = Medicare won't cover these services because they are not considered medically necessary. 23.2 = Cosmetic surgery and related services are not covered. 23.3 = Medicare does not pay for surgical supports except primary dressings for skin grafts. 23.4 = A separate charge is not allowed because this service is part of the major surgical procedure. 23.5 = Payment has been reduced because a different doctor took care of you before and/or after the surgery. 23.6 = This surgery was reduced because it was performed with another surgery on the same day. 23.7 = Payment cannot be made for an assistant surgeon in a teaching hospital unless a resident doctor was not available. 23.8 = This service is not payable because it is part of the total maternity care charge. 23.9 = Payment has been reduced because the charges billed did not include post- operative care. Section 24 'Help Stop Fraud' messages 24.1 = Protect your Medicare number as you would a credit card number. 24.10 = Always read the front and back of your Medicare Summary Notice. 24.11 = Beware of Medicare scams, such as offers of free milk or cheese for your Medicare number. 24.12 = Read your Medicare Summary Notice carefully for accuracy of dates, services , and amounts billed to Medicare. 24.13 = Be sure you understand anything you are asked to sign. 24.14 = Be sure any equipment or services you received were ordered by your doctor. 24.15 = Review your Medicare Summary Notice and report items and services that you did not receive to Medicare's Fraud Hotline at 1-866-417-2078. FLORIDA - SPECIFIC MESSAGE 24.16 = Report items and services that you did not receive to Medicare's Fraud Hotline at 1-866-417-2078. FLORIDA - SPECIFIC MESSAGE 24.19 = You may see some claims that have been adjusted. For an explanation see the General Information section See Expiration Date and Message Notes -------> 24.2 = Beware of telemarketers or advertisements offering free or discounted Medicare items and services. 24.22 = You can make a difference! Last year, tax-payers saved $4 billion-the largest sum ever recovered in a single year- thanks in large part to people who came forward and reported suspicious activity. See "Message Implementation Date" and "Message Notes" columns. ----> 24.3 = Beware of door-to-door solicitors offering free or discounted Medicare items or services. 24.4 = Only your physician can order medical equipment for you. 24.5 = Always review your Medicare Summary Notice for correct information about the items or services you received. 24.6 = Do not sell your Medicare number or Medicare Summary Notice. 24.7 = Do not accept free medical equipment you don't need. 24.8 = Beware of advertisements that read, "This item is approved by Medicare", or "No out-of-pocket expenses." 24.9 = Be informed - Read your Medicare Summary Notice. See "Message Expiration Date" and "Message Notes" columns -----> Section 25 Time Limit for filing 25.1 = This claim was denied because it was filed after the time limit. 25.2 = You can be billed only 20% of the charges that would have been approved. 25.3 = The time limit for filing your claim has expired, therefore appeal rights are not applicable for this claim. Section 26 Vision 26.1 = Eye refractions are not covered. 26.2 = Eyeglasses or contact lenses are only covered after cataract surgery or if the natural lens of your eye is missing. 26.3 = Only one pair of eyeglasses or contact lenses is covered after cataract surgery with lens implant. 26.4 = This service is not covered when performed by this provider. 26.5 = This service is covered only in conjunction with cataract surgery. 26.6 = Payment was reduced because the service was terminated early. Section 27 Hospice 27.1 = This service is not covered because you are enrolled in a hospice. 27.10 = The documentation indicates that the service level of continuous home care wasn't reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate. 27.11 = The provider has billed in error for the routine home care items or services received. 27.12 = The documentation indicates that your respite level of care exceeded five consecutive days. Therefore, payment for every day beyond the 5th day will be paid at the routine home care rate. 27.13 = According to Medicare hospice requirements, this service is not covered because the service was provided by a non-attending physician. 27.2 = Medicare will not pay for inpatient respite care when it exceeds five consecutive days at a time. 27.3 = The physician certification requesting hospice services was not received timely. 27.4 = The documentation received indicates that the general inpatient care level of services were not necessary for care related to the terminal illness. Therefore, payment will be adjusted to the routine home care rate. 27.5 = Payment for the day of discharge from the hospital will be made to the hospice agency at the routine home care rate. 27.6 = The documentation indicates the level of care was at the respite level not the general inpatient level of care. Therefore, payment will be adjusted to the routine home care rate. 27.7 = According to Medicare hospice requirements, the hospice election consent was not signed timely. 27.8 = The documentation submitted does not support that your illness is terminal. 27.9 = The documentation indicates your inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate. 27.99 = Medicare allows your doctor to charge for developing a plan of treatment for your home health or hospice services. Section 28 Mandatory 28.1 = Because you have Medicaid, your provider must agree to accept assignment. Section 29 MSP 29.1 = Secondary payment cannot be made because the primary insurer information was either missing or incomplete. 29.10 = These services cannot be paid because you received them on or before you received a liability insurance payment for this injury or illness. 29.11 = Our records show that an automobile medical, liability, or no-fault insurance plan is primary for these services. Submit this claim to the primary payer. 29.12 = Our records show that these services may be covered under the Black Lung Program. Contact the U.S. Department of Labor, Federal Black Lung Program, P.O. Box 8302 , London, KY 40742-8302 29.13 = Medicare does not pay for these services because they are payable by another government agency. Submit this claim to that agency. 29.14 = Medicare's secondary payment is ($______) . This is the difference between the primary insurer's approved amount of ($______) and the primary insurer's paid amount of ($______). 29.15 = Medicare's secondary payment is ($______) . This is the difference between Medicare's approved amount of ($______) and the primary insurer's paid amount of ($______). 29.16 = Your primary insurer approved and paid ( $______) on this claim. Therefore, no secondary payment will be made by Medicare. 29.17 = Your provider agreed to accept ($______) as payment in full on this (claim/service ). Your primary insurer has already paid ($______) so Medicare's payment is the difference between the two amounts. 29.18 = The amount listed in the "You May Be Billed" column assumes that your primary insurer paid the provider. If your primary insurer paid you, then you are responsible to pay the provider the amount your primary insurer paid to you plus the amount in the "You May Be Billed " column. This message should be revised to read "If your primary insurer paid you for this claim, you are responsible to pay that amount to your provider plus the amount in the "Maximum You May Be Billed" column." See "Message Implementation Date" and "Message Notes" columns. 29.19 = If your primary insurer paid your provider for this claim, you now only need to pay your provider the difference between the amount charged and the amount your primary insurer paid. 29.2 = No payment was made because your primary insurer's payment satisfied the provider's bill. 29.20 = If your primary insurer paid your provider for this claim, you only need to pay the difference between the amount your provider agreed to accept and the amount your primary insurer paid. 29.21 = If your primary insurer made payment on this claim, you may be billed the difference between the amount charged and your primary insurer's payment. 29.22 = If your primary insurer paid the provider , you need to pay the provider the difference between the limiting charge amount and the amount the primary insurer paid your provider. 29.23 = No payment can be made because payment was already made by either worker's compensation or the Federal Black Lung Program. 29.24 = No payment can be made because payment was already made by another government entity. 29.25 = Medicare paid all covered services not paid by other insurer. 29.26 = The primary payer is _________. 29.27 = Your primary group's payment satisfied Medicare deductible and coinsurance. 29.28 = Your responsibility on this claim has been reduced by the amount paid by your primary insurer. 29.29 = Your provider is allowed to collect a total of ($______) on this claim. Your primary insurer paid ($_____) and Medicare paid ($______). You are responsible for the unpaid portion of ($______). 29.3 = Medicare benefits are reduced because some of these expenses have been paid by your primary insurer. 29.30 = ($______) of the money approved by your primary insurer has been credited to your Medicare Part B (A) deductible. You do not have to pay this amount. 29.31 = Resubmit this claim with the missing or correct information. 29.32 = Medicare's secondary payment is ($______) . This is the difference between Medicare's limiting charge amount of ($______) and the primary insurer's paid amount of ($______). 29.33 = Your claim has been denied by Medicare because you may have funds set aside from your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies). 29.34 = The claim for this item/service was submitted by your complementary insurer on your behalf. 29.35 = Per statute, Medicare only accepts claims from your complementary insurer when Medicare is the primary payer. 29.71 = Medicare benefits are being paid on the condition that if you receive payment from liability insurance, an automobile medical insurance policy or plan, or any other no-fault insurance, you must repay Medicare. 29.4 = In the future, if you send claims to Medicare for secondary payment, please send them to (carrier MSP address). 29.5 = Our records show that Medicare is your secondary payer. This claim must be sent to your primary insurer first. 29.6 = Our records show that Medicare is your secondary payer. Services provided outside your prepaid health plan are not covered. We will pay this time only since you were not previously notified. 29.7 = Medicare cannot pay for this service because it was furnished by a provider who is not a member of your employer prepaid health plan. Our records show that you were informed of this rule. 29.8 = This claim is denied because the service(s) may be covered by the worker's compensation plan. Ask your provider to submit a claim to that plan. 29.9 = Since your primary insurance benefits have been exhausted, Medicare will be primary on this accident related service. Section 3 Chiropractic 3.1 = This service is covered only when recent x-rays support the need for the service. 3.7 = Medicare does not pay for this unless a sympton or sign of a problem is stated on the claim. 3.18 = This represents an adjustment of a previously processed claim. If an underpayment was made, the attached check pays the total claim allowed minus the amount originally paid. If an overpayment requiring a refund was made and a refund has not already been submitted, you will be contacted by letter from the Medicare claims office. Section 30 Reasonable Charge and Fee Schedule 30.1 = The approved amount is based on a special payment method. 30.2 = The facility fee allowance is greater than the billed amount. 30.3 = Your doctor did not accept assignment for this service. Under Federal law, your doctor cannot charge more than ($______) . If you have already paid more than this amount, you are entitled to a refund from the provider. 30.4 = A change in payment methods has resulted in a reduced or zero payment for this procedure. 30.41 = What Medicare pays for a service or item may be higher than the billed amount. This amount is correct. Medicare pays this provider less than the billed amount on other claims since payment rates are set in advance for certain services and averaged out over an entire year. 30.5 = This amount is the difference in billed amount and Medicare approved amount. Section 31 Adjustments 31.1 = This is a adjustment to a previously processed claim and/or deductible record. 31.10 = This is an adjustment to a previously processed charge (s). This notice may not reflect the charges as they were originally submitted. 31.11 = The previous notice we sent stated that your doctor could not charge more than ($______). This additional payment allows your doctor to bill you the full amount charged. 31.12 = The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than ($______). 31.13 = The Medicare paid amount has been reduced by ($______) previously paid for this claim. 31.14 = This payment is the result of an Administrative Law Judge's decision. 31.15 = An adjustment was made based on a redetermination. 31.16 = An adjustment was made based on a reconsideration. 31.17 = This is an internal adjustment. No action is required on your part. 31.18 = This adjustment has resulted in an overpayment to your provide/supplier. Your provider/supplier has been requested to repay $________ to Medicare. You do not have to pay this amount. 31.19 = If you do not agree with the Medicare approved amount(s), you may ask for a reconsideration. You must request a reconsideration within 180 days of the date of receipt of this notice. You may present any new evidence which could affect your decision. Call us at the number in the Customer Service block if you need more information about the reconsideration process. This message should be revised to read, "If you disagree with the Medicare- approved amount, you may ask for a redetermination within 120 days of receipt of this notice. Call 1-800-MEDICARE if you need information on the redetermination process." when your MAC implements the new MSN design. See "Message Implementation Date" and "Message Notes" colums. -----> 31.2 = A payment adjustment was made based on a telephone review. 31.3 = This notice is being sent to you as the result of a reopening request. 31.4 = This notice is being sent to you as the result of a fair hearing request. 31.5 = If you do not agree with the Medicare approved amount(s) and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing. You must request a hearing within 6 months of the date of this notice. To meet the limit you may combine amounts on other claims that have been reviewed. At the hearing, you may present any new evidence which could affect the decision. Call us at the number in the Customer Service block if you need more information about the hearing process. 31.6 = A payment adjustment was made based on a Quality Improvement Organization request. 31.7 = This claim was previously processed under an incorrect Medicare claim number or name. Our records have been corrected. 31.8 = This claim was adjusted to reflect the correct provider. 31.9 = This claim was adjusted because there was an error in billing. 31.95 = Per our telephone call, no payment can be made on your review request. The approved amount is the total allowance we can make for this service. 31.96 = Per our telephone call, no payment can be made on your review request. Medicare does not separately pay for these charges because the cost of related care before and after the surgery/procedure is part of the approved amount for the surgery/ procedure. 31.97 = Per our telephone call, no payment can be made on your review request. Medicare does not pay for this many services within this period of time. 31.98 = Per our telephone call, no payment can be made on your review request. Medicare does not pay for routine foot care. 31.99 = As a result of the Hearing Officer's decision, no additional payment can be made. Section Overpayments/Offsets 32.1 = ($______) of this payment has been withheld to recover a previous overpayment. 32.2 = You should not be billed separately by your physician(s) for services provided during this inpatient stay. 32.3 = Medicare has paid $_______ for hospital and doctor services. You shouldn't be billed separately by your doctor(s) for services you got during this inpatient stay. Section 33 Ambulatory Surgical Centers 33.1 = The ambulatory surgical center must bill for this service. Section 34 Patient Paid/Split Payments 34.1 = Of the total ($______) paid on this claim , we are paying you ($______) because you paid your provider more than your 20% coinsurance on Medicare approved services. The remaining ($______) was paid to the provider. 34.2 = The amount in the "You May Be Billed" column has been reduced by the amount you paid the provider at the time the services were rendered. This message should be revised to read "Maximum You May Be Billed" (in place of "You May Be Billed") when your MAC implements the new MSN design. See "Message Implementation Date" and "Message Notes" columns. ------> 34.3 = After applying Medicare guidelines and the amount you paid to the provider at the time the services were rendered, our records indicate you are entitled to a refund. Please contact your provider. 34.4 = We are paying you ($______) because the amount you paid the provider was more than you may be billed for Medicare approved charges. 34.5 = The amount owed you is ($______). Medicare does not routinely issue checks for amounts under $1.00. This amount due will be included in your next check. If you want this money issued immediately , please contact us at the address or phone number in the Customer Service Information box. The last sentence of this message should be revised to read, "If you want this money issued immediately, please call 1-800-MEDICARE (1-800-633-4227)." when your MAC implements the new MSN design. See "Message Implementation Date" and Message Notes" columns. 34.6 = Your check includes ($_____) which was withheld on a prior claim. 34.7 = This check includes an amount less than $1.00 that was withheld on a prior claim. 34.8 = The amount you paid the provider for this claim was more than the required payment. You should be receiving a refund of ($_____) from your provider, which is the difference between what you paid and what you should have paid. 34.9 = If you already paid the supplier/provider , the supplier/provider must refund any amount that exceeds the Medicare approved amount. Section 35 Supplemental Coverage/Medigap 35.1 = This information is being sent to your private insurer(s). Send any questions regarding your benefits to them. 35.2 = We have sent your claim to your Medigap insurer. Send any questions regarding your benefits to them. 35.3 = A copy of this notice will not be forwarded to your Medigap insurer because the Medigap information submitted on the claim was incomplete or invalid. Please submit a copy of this notice to your Medigap insurer. 35.4 = A copy of this notice will not be forwarded to your Medigap insurer because your provider does not participate in the Medicare program. Please submit a copy of this notice to your Medigap insurer. 35.5 = We did not send this claim to your private insurer. They have indicated no additional payment can be made. Send any questions regarding your benefits to them 35.6 = Your supplemental policy is not a Medigap policy under Federal and State law or regulation. It is your responsibility to file a claim directly with your insurer. 35.7 = Please do not submit this notice to them (add-on to other messages as appropriate). Section 36 Limitation of Liability 36.1 = Our records show that you were informed in writing, before receiving the service that Medicare would not pay. You are liable for this charge. If you do not agree with this statement, you may ask for a review. 36.2 = You didn't know this service isn't covered so you don't have to pay. If you paid and do not receive a refund from your provider, you have 6 months to send a copy of this notice, your provider's bill, and proof that you paid to the address on the last page of this notice. Future services of this type won't be paid. 36.3 = Your provider was told that you're owed a refund for this service. If you don't get a refund within 30 days of getting this notice, send a copy of this notice to the address on the last page. Refunds may be delayed if your provider appeals this decision. 36.4 = You are getting a refund because your provider didn't tell you in writing that Medicare wouldn't pay for this service. In the future, you will have to pay for the service. 36.5 = You are getting a refund because your provider didn't tell you in writing that Medicare would approve a reduced level/ amount of services. In the future, you will have to pay for the service. 36.6 = Medicare is paying this claim, this time only, because it appears that neither you nor the provider knew that the service(s) would be denied. You will have to pay for future services of this type. 36.7 = This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount. Section 37 Deductible/Coinsurance 37.1 = This approved amount has been applied toward your deductible. 37.10 = You have now met ($______) of your ($______) Part A deductible for this benefit period. 37.11 = You have met the Part B deductible for (year). 37.12 = You have met the Part A deductible for this benefit period. 37.13 = You have met the blood deductible for (year). 37.14 = You have met ($______) pint(s) of your blood deductible for (year). 37.15 = After your deductible and coinsurance were applied, the amount Medicare paid was reduced due to Federal, State and local rules. 37.16 = You have now met $_______ of your $_______ Part B deductible for calendar year ____. 37.17 = The "Maximum You May Be Billed" column includes $_______ for your Part B deductible, $_______ for your Part B coinsurance, $_______ for your Part A deductible, and $_______ for your Part A coinsurance and/or lifetime reserve coinsurance. *If your MAC will implement the new MSN design AFTER 07/01/13, use the following language for this message from 07/01/13 until your MAC DOES implement the new MSN design: The "You May Be Billed" column includes $_______ for your Part B deductible, $_______ for your Part B coinsurance, $_______ for your Part A deductible, and $_______ for your Part A coinsurance and/or lifetime reserve coinsurance. 37.2 = ($______) of this approved amount has been applied toward your deductible. 37.3 = ($______) was applied to your inpatient deductible. 37.4 = ($______) was applied to your inpatient coinsurance. 37.5 = ($______) was applied to your skilled nursing facility coinsurance. 37.6 = ($______) was applied to your blood deductible. 37.7 = Part B cash deductible does not apply to these services. 37.8 = This coinsurance amount reflects the amount that you are required to pay for outpatient mental health treatment services under the Medicare program. 37.9 = You have now met ($______) of your ($______) Part B deductible for (year). Section 38 General Information 38.1 = Discontinued 2002 38.10 = Compare the services you receive with those that appear on your Medicare Summary Notice. If you have questions, call your doctor or provider. If you feel further investigation is needed due to possible fraud or abuse, call the phone number in the Customer Service Information Box. The last sentence of this message should be revised to read, "If you feel further investigation is needed due to possible fraud or abuse, call 1-800-MEDICARE (1-800-633-4227)." when your MAC implements the new MSN design. See "Message Implementation Date" and Message Notes" columns. -----> 38.11 = Preventive Messages: January - Cervical Health January is cervical health month. The Pap test is the most effective way to screen for cervical cancer. Medicare helps pay for screening Pap tests every two years. For more information on Pap tests, call your Medicare carrier. January - National Glaucoma Awareness Month (Optional) Glaucoma may cause blindness. Medicare helps pay for a yearly dilated eye exam for people at high risk for Glaucoma. African-Americans over 50 and people with diabetes or a family history of glaucoma are at higher risk. Talk to your doctor to learn if this exam is right for you. February - General Preventive Services Medicare helps pay for many preventive services including flu and pneumococcal shots, tests for cancer, diabetes monitoring supplies and others. Call 1-800-MEDICARE (1-800-633-4227) for more information. March - National Colorectal Cancer Awareness Month Colorectal cancer is the second leading cancer killer in the United States. Medicare helps pay for colorectal cancer screening tests. Talk to your doctor about screening options that are right for you. April - General Preventive Services Medicare helps pay for many preventive services including flu and pneumococcal shots, tests for cancer, diabetes monitoring supplies and others. Call 1-800-MEDICARE (1-800-633-4227) for more information. May - National Osteoporosis Month Do you know how strong your bones are? Medicare helps pay for bone mass measurement tests to measure the strength of bones for people at risk of osteoporosis. Talk to your doctor to learn if this test is right for you. May - Breast Cancer Awareness (to coordinate with Mother's Day) - Optional Early detection is the best protection from breast cancer. Get a mammogram. Not just once, but for a lifetime. Medicare helps pay for screening mammograms. June - General Preventive Services Message: Medicare helps pay for many preventive services including flu and pneumococcal shots, tests for cancer, diabetes monitoring supplies and others. Call 1-800-MEDICARE (1-800-633-4227) for more information. July- Glaucoma Awareness Glaucoma may cause blindness. Medicare helps pay for a yearly dilated eye exam for people at high risk for Glaucoma. African-American people over 50, and people with diabetes or a family history of glaucoma are at higher risk. Talk to your doctor to learn if this exam is right for you. August - National Immunization Awareness Month (Contractors may elect to print this message during a different month of their choosing, but the message about the pneumococcal shot must be printed one month of each year.) Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment September - Cold and Flu Campaign During this flu season, get your flu shot . Contact your health care provider for the flu shot. Get the flu shot, not the flu. You pay nothing if your health care provider accepts Medicare assignment. September - Prostate Cancer Awareness Month - Optional Prostate cancer is the second leading cause of cancer deaths in men. Medicare covers prostate screening tests once every 12 months for men with Medicare who are over age 50. October - Breast Cancer Awareness Month Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. October - Continuation of Cold/Flu Campaign (optional) If you have not received your flu shot, it is not too late. Please contact your health care provider about getting the flu shot. November - American Diabetes Month Medicare covers expanded benefits to help control diabetes Section 38 General Information 38.12 = If you appeal this drug claim determination, send it to the Medicare contractor who processed your doctor's claim for giving you the drug. 38.13 = If you aren't due a payment check from Medicare, your Medicare Summary Notices (MSN) will now be mailed to you on a quarterly basis. You will no longer get a monthly statement in the mail for these types of MSNs. You will now get a statement every 90 days summarizing all of your Medicare claims. Your provider may send you a bill that you may need to pay before you get your MSN. When you get your MSN, look to see if you paid more than the MSN says is due. If you paid more, call your provider about a refund. If you have any questions about the bill from your provider, you should call your provider. 38.14 = Have limited income? Social Security can help with prescription drug costs. For more information on Extra Help with prescription drug costs and how to apply, visit www.socialsecurity.gov on the web or call 1-800-772-1213. TTY users should call 1-800-325-0778. 38.15 = If the coinsurance amount you paid is more than the amount shown on your notice , you are entitled to a refund. Please contact your provider. 38.18 = ALERT: Coverage by Medicare will be limited for outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services for services received on January 1, 2006 through December 31, 2007. The limits are $1,740 in 2006 and $1780 in 2007 for PT and SLP combined and $1,740 in 2006 and $1780 in 2007 for OT. Medicare pays up to 80 percent of the limits after the deductible has been met. These limits don't apply to certain therapy approved by Medicare or to therapy you get at hospital outpatient departments, unless you are a resident of and occupy a Medicare-certified bed in a skilled nursing facility. If you have questions, please call 1-800-MEDICARE. You have the right to request an itemized statement which details each Medicare item or service which you have received from your physician, hospital, or any other health supplier or health professional. Please contact them directly, in writing, if you would like an itemized statement. Beneficiaries needing or receiving home health care may qualify for the new Home Health Independence Demonstration and have the freedom to leave home more often while remaining eligible for Medicare home health services. To qualify, you must meet several criteria, have a permanent disabling condition, and live in Colorado, Massachusetts, or Missouri. For more information, ask your home health agency about the "Home Health Independence Demonstration"; call 1(800) MEDICARE (1-800-633-4227); or visit our website at: www.cms.hhs.gov/researchers/ demos/homehealthindependence.asp 38.18 = ALERT: Coverage by Medicare will be limited for outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services for services received on January 1, 2006 through December 31, 2007. The limits are $1,740 in 2006 and $1780 in 2007 for PT and SLP combined and $1,740 in 2006 and $1780 in 2007 for OT. Medicare pays up to 80 percent of the limits after the deductible has been met. These limits don't apply to certain therapy approved by Medicare or to therapy you get at hospital outpatient departments, unless you are a resident of and occupy a Medicare-certified bed in a skilled nursing facility. If you have questions, please call 1-800-MEDICARE. 38.19 = Medicare Open Enrollment is from October 15 to December 7. This is when you can compare and change your health and drug plan coverage. If you're happy with your current plan, you don't have to do anything. Call 1-800-MEDICARE (1 800-633- 4227) for more information. 38.2 = Discontinued 38.20 = You have the right to request an itemized statement which details each Medicare item or service you have received from a physician, hospital, or any other healthcare provider or supplier. Contact your provider to get an itemized statement. 38.22 = Planning to retire? Does your current insurance pay before Medicare pays? Call Medicare within the 6 months before you retire to update your records. Make sure your health care bills get paid correctly 38.23 = Save tax dollars by getting your "Medicare & You" handbook electronically. Visit www.mymedicare.gov to sign up. 38.24 = Please have your complete Medicare number with you when you call so your record can be located. To protect your privacy, this MSN doesn't include your entire number. 38.25 = This item or service is being denied. Medicare won't pay for a Medical Nutrition Therapy service and Diabetes Self Management Training item or service performed on the same date for the same person with Medicare. 38.26 = Your claims may have been adjusted since Medicare changed how it pays for certain services in 2010. You can compare claims that have been changed to previous statements you received in the past. Your provider may owe you a refund or you may have to pay more coinsurance. Call your provider or 1-800-MEDICARE. 38.27 = Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment 38.28 = Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. 38.3 = If you change your address, contact the Social Security Administration by calling 1-800-772-1213. 38.31 = To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 38.32 = Welcome to your new Medicare Summary Notice! It has clear language, larger print, and a personal summary of your claims and deductibles. This improved notice better explains how to get help with your questions, report fraud, or file an appeal. It also includes important information from Medicare! 38.4 = You're at high risk for complications from the flu and it's very important that you get vaccinated. Please contact your healthcare provider about getting the flu vaccine. 38.5 = If you haven't gotten your flu vaccine, it isn't too late. Please contact your health care provider about getting the vaccine. 38.6 = January is cervical cancer prevention month. 38.7 = The Pap test is the most effective way to screen for cervical cancer. 38.8 = Medicare helps pay for screening Pap tests once every two years. 38.9 = Colorectal cancer is the second leading cancer killer in the United States. Medicare helps pay for screening tests that can find polyps before they become cancerous and find cancer early when treatment may work best. Medicare helps pay for screening tests. Talk to your doctor about the screening options that are right for you. Section 4 End-Stage Renal Disease (ESRD) 4.1 = This charge is more than Medicare pays for maintenance treatment of renal disease. 4.10 = No more than ($______) can be paid for these supplies each month. 4.11 = The amount listed in the "You May Be Billed" column is based on the Medicare approved amount. You are not responsible for the difference between the amount charged and the approved amount. This message should be revised to read "Maximum You May Be Billed" (in place of "You May Be Billed") when your MAC implements the new MSN design. 4.12 = This service has been denied/rejected since payment was made to your End Stage Renal Disease (ESRD) dialysis facility. 4.18 = Medicare cannot pay more than $_____ each month for these supplies. The provider cannot bill you for the supplies over this limit. 4.2 = This service is covered up to (insert appropriate number) months after transplant and release from the hospital. 4.3 = Prescriptions for immunosuppressive drugs are limited to a 30-day supply. 4.4 = Only one supplier per month may be paid for these supplies/services. 4.5 = Medicare pays the professional part of this charge to the hospital. 4.6 = Payment has been reduced by the number of days you were not in the usual place of treatment. 4.7 = Payment for all equipment and supplies is made through your dialysis center. They will bill Medicare for these services. 4.8 = This service cannot be paid because you did not choose an option for your dialysis equipment and supplies. 4.9 = Payment was reduced or denied because the monthly maximum allowance for this home dialysis equipment and supplies has been reached. Section 41 Home Health Messages 41.1 = Medicare will only pay for this service when it is provided in addition to other services. 41.10 = Patients eligible to receive home health benefits from another government agency are not eligible to receive Medicare benefits for the same service. 41.11 = The doctor's orders for home health services were incomplete. 41.12 = According to the medical record, the provider has billed in error for these items/services. 41.13 = The provider has billed for services/ items not documented in your record. 41.14 = This service/item was billed incorrectly. 41.15 = The information provided indicates that you are able to perform personal care activities on your own. 41.16 = To receive Medicare payment, you must have a signed doctor's order before you receive the services. 41.2 = This service must be performed by a nurse who has the required psychiatric nurse credentials. 41.3 = The medical information did not support the need for continued services. 41.4 = Medicare considers this item to be inappropriate for home use. 41.5 = Medicare does not pay for comfort or convenience items. 41.6 = This item was not furnished under a plan of care established by your physician. 41.7 = This item is not considered by Medicare to be a prosthetic and/or orthotic device 41.8 = The information provided indicates that your illness or injury doesn't restrict your ability to leave your home, except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker). 41.9 = Services exceeded those ordered by your physician. Section 42 Religious Nonmedical Health Care Institutions 42.1 = You received medical care at a facility other than a religious nonmedical health care institution but that care did not revoke your election to receive benefits for religious nonmedical health care. 42.2 = Since you received medical care at a facility other than a religious nonmedical health care institution, benefits for religious nonmedical health care services have been revoked for these services unless you file a new election. 42.3 = This service is not covered since you did not elect to receive religious nonmedical health care services instead of regular Medicare services. 42.4 = This service is not covered because you received medical health care services which revoked your election to religious nonmedical health care services. 42.5 = This service is not covered because you requested in writing that your election to religious nonmedical health care services be revoked. Section 5 Number/Name/Enrollment 5.1 = Our records show that you do not have Medicare entitlement under the number shown on this notice. If you do not agree, please contact your local Social Security office. 5.2 = The name or Medicare number was incorrect or missing. Please check your Medicare card. If the information on this notice is different from your card, contact your provider. 5.3 = Our records show that the date of death was before the date of service. 5.4 = If you cash the enclosed check, you are legally obligated to make payment for these services. If you do not wish to assume this obligation, please return this check. 5.5 = Our records show you did not have Part A (B) coverage when you received this service. If you disagree, please contact us at the customer service number shown on this notice. 5.6 = The name or Medicare number was incorrect or missing. Ask your provider to use the name or number shown on this notice for future claims. 5.7 = Medicare payment may not be made for the item or service because on the date of service you were not lawfully present in the United States. Section 6 Drugs 6.1 = This drug is covered only when Medicare pays for the transplant. 6.2 = Drugs not specifically classified as effective by the Food and Drug Administration are not covered. 6.3 = Payment cannot be made for oral drugs that do not have the same active ingredients as they would have if given by injection. 6.4 = Medicare does not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours after administration of a Medicare covered chemotherapy drug. 6.5 = Medicare cannot pay for this injection because one or more requirements for coverage were not met. Section 43 Demonstration Project Messages 60.1 = In partnership with physicians in your area, ____________ is participating in a Medicare demonstration project that uses a simplified payment method to combine all hospital and physician care related to your hospital service. 2/18/13= Even though this service is being paid in accordance with the rules and guidelines under the Competitive Bidding Demonstration, future claims may be denied when this item is provided to this patient by a non-demonstration supplier. If you would like more information egarding this project, you may contact 1-888-289-0710. 60.11 = These services are covered by a demonstration project or payment model pilot. It will pay for all services related to this hospital stay. If you have already paid a provider for any of these services, you should receive a refund. 60.12 = Your co-payment under this demonstration is the lesser of 20% of the Medicare allowed amount or 20% of the allowed amount under your drug discount card. 60.13 = This claim is being processed under a demonstration project. Services cannot be covered because you do not reside in one of the demonstration areas. 60.14 = This claim is being processed under a demonstration project. Services cannot be covered because your doctor does not have a practice in one of the demonstration areas. 60.15 = Beginning April 1, 2005 through March 31, 2007, Medicare will cover additional chiropractic services. For more information, talk to your chiropractor, call 1-800-MEDICARE, or go to http://www.cms.hhs.gov/researchers/demos /eccs/default.asp. 60.16 = This claim is being processed under a demonstration or payment model pilot. All hospital and doctor services related to your hospital stay have been combined into a single payment. You may have to pay any unmet deductible and coinsurance amounts. 60.2 = The total Medicare approved amount for your hospital service is ($______). ($______) is the Part A Medicare amount for hospital services and ($_______) is the Part B Medicare amount for physician services (of which Medicare pays 80 percent). You are responsible for any deductible and coinsurance amounts represented. 60.3 = Medicare has paid ($______) for hospital and physician services. Your Part A deductible is ($______). Your Part A coinsurance is ($______) Your Part B coinsurance is ($______). 60.4 = This claim is being processed under a demonstration project. 60.5 = This claim is being processed under a demonstration project. If you would like more information about this project, please contact 1-888-289-0710. 60.6 = A claim has been submitted on your behalf indicating that you are participating in the Medicare Coordinated Care Demonstration project. However, our records indicate that you are not currently enrolled or your enrollment has not yet been approved for the demonstration. 60.7 = A claim has been submitted on your behalf indicating that you are participating in the Medicare Coordinated Care Demonstration project. However, our records indicate that either you have terminated your election to participate in the demonstration project or the dates of service are outside the demonstration participation dates. 60.8 = The approved amount is based on the maximum allowance for this item under the DMEPOS Competitive Bidding Demonstration. 60.9 = Our records indicate that this patient began using this service(s) prior to the current round of the DMEPOS Competitive Bidding Demonstration. Therefore, the approved amount is based on the allowance in effect prior to this round of bidding for this item. Section 7 Duplicate Bills 7.1 = This is a duplicate of a charge already submitted. 7.15 = Medicare records show that payment for this service has already been made by another contractor. 7.2 = This is a duplicate of a claim processed by another contractor. You should receive a Medicare Summary Notice from them. 7.3 = This service/item is a duplicate of a previously processed service. You may only appeal the decision that this service/item is a duplicate. The appeals information on this notice only applies to the duplicate service issue. 7.4 = The claim for the billing fee was denied because it was submitted past the allowed time frame. 7.7 = Your physician has elected to participate in the Competitive Acquisition Program for these drugs. Claims for these drugs must be billed by the appropriate drug vendor instead of your physician. 7.8 = Your physician has elected to participate in the Competitive Acquisition Program (CAP) for Medicare Part B drugs. Medicare cannot pay for the administration of the drug(s) being billed because these drug(s) are not available from the CAP vendor. Section 8 Durable Medical Equipment (DME) 8.1 = Your supplier is responsible for the servicing and repair of your rented equipment. 8.2 = To receive Medicare payment, you must have a doctor's prescription before you rent or purchase this equipment. 8.10 = Payment is included in the approved amount for other equipment. 8.11 = The purchase allowance has been reached. If you continue to rent this piece of equipment, the rental charges are your responsibility. 8.12 = The approved charge is based on the amount of oxygen prescribed by the doctor 8.13 = Monthly rental payments can be made for up to 15 months from the first paid rental month or until the equipment is no longer needed, whichever comes first. 8.14 = Your equipment supplier must furnish and service this item for as long as you continue to need it. Medicare will pay for maintenance and/or servicing for every 6 month period after the end of the 15th paid rental month. 8.15 = Maintenance and/or servicing of this item is not covered until 6 months after the end of the 15th paid rental month. 8.16 = Monthly allowance includes payment for oxygen and supplies. 8.17 = Payment for this item is included in the monthly rental payment amount. 8.18 = Payment is denied because the supplier did not have a written order from your doctor prior to delivery of this item. 8.19 = Sales tax is included in the approved amount for this item. 8.2 = To receive Medicare payment, you must have a doctor's prescription before you rent or purchase this equipment. 8.20 = Medicare does not pay for this equipment or item. 8.21 = Medicare won't cover this item without a new, revised or renewed certificate of medical necessity. 8.22 = No further payment can be made because the cost of repairs has added up to the purchase price of this item. 8.23 = No payment can be made because the item has reached the 15-month limit. Separate payments can be made for maintenance or servicing every 6 months. 8.24 = The claim doesn't show that you own the equipment requiring these parts or supplies. 8.25 = Payment cannot be made until you tell your supplier whether you want to rent or buy this equipment. 8.26 = Payment is reduced by 25% beginning the 4th month of rental. 8.27 = Payment is limited to 13 monthly rental payments because you have decided to purchase this equipment. 8.28 = Maintenance, servicing, replacement, or repair of this item is not covered. 8.29 = Payment is allowed only for the seat lift mechanism, not the entire chair. 8.3 = This equipment is not covered because its primary use is not for medical purposes. 8.30 = This item is not covered because the doctor did not complete the certificate of medical necessity. 8.31 = Payment is denied because blood gas tests cannot be performed by a durable medical equipment supplier. 8.32 = This item can only be rented for 2 months . If the item is still needed, it must be purchased. 8.33 = This is the next to last payment for this item. 8.34 = This is the last payment for this item. 8.35 = This item is not covered when oxygen is not being used. 8.36 = Payment is denied because the certificate of medical necessity on file was not in effect for this date of service. 8.37 = An oxygen recertification form was sent to the physician. 8.38 = This item must be rented for 2 months before purchasing it. 8.39 = This is the 10th month of rental payment. Your supplier should offer you the choice of changing the rental to a purchase agreement. 8.4 = Payment can't be made for equipment that's the same or similar to equipment already being used. 8.40 = We have previously paid for the purchase of this item. 8.41 = Payment for the amount of oxygen supplied has been reduced or denied because the monthly limit has been reached. 8.42 = Standby equipment is not covered. 8.43 = Payment has been denied because this equipment cannot deliver the liters per minute prescribed by your doctor. 8.44 = Payment is based on a standard item because information did not support the need for a deluxe or more expensive item. 8.45 = Payment for electric wheelchairs is allowed only if the purchase decision is made in the first or tenth month of rental. 8.46 = Payment is included in the allowance for another item or service provided at the same time. 8.47 = Supplies or accessories used with noncovered equipment are not covered. 8.48 = Payment for this drug is denied because the need for the equipment has not been established. 8.49 = This allowance has been reduced because part of this item was paid on another claim. 8.5 = Rented equipment that is no longer needed or used is not covered. 8.50 = Medicare can't pay for this drug/ equipment because our records show that your supplier isn't licensed to dispense prescription drugs, and, therefore, can't assure the safety and effectiveness of the drug/equipment. 8.51 = You are not liable for any additional charge as a result of receiving an upgraded item. 8.52 = You signed an Advanced Beneficiary Notice (ABN). You are responsible for the difference between the upgrade amount and the Medicare payment. 8.53 = This item or service was denied because the upgrade information was invalid. 8.54 = If a supplier knew that Medicare wouldn't pay and you paid, you might get a refund unless you signed a notice in advance. Refunds may be delayed if the provider appeals. Call your supplier if you don't hear anything within 30 days. 8.55 = Medicare will process your first claim but, from now on, you must use a Medicare-enrolled supplier and put the supplier ID number on your claim. For a list of Medicare-enrolled suppliers call 1-800-MEDICARE or visit www.medicare.gov/ supplier 8.56 = Medicare can't process this claim because you were already notified that you must use a supplier who has a Medicare supplier identification number, and this supplier doesn't have one. 8.57 = Your equipment supplier must furnish and service this item for as long as you continue to need it. Medicare will pay for maintenance and/or servicing for every 3-month period after the end of the 15th paid rental month. 8.58 = No payment can be made because the item has reached the 15-month limit. Separate payments can be made for maintenance or servicing every 3 months. 8.59 = Durable Medical Equipment Regional Carriers only pay for Epoetin Alfa and Darbepoetin Alfa for Method II End Stage Renal Disease home dialysis patients. 8.6 = A partial payment has been made because the purchase allowance has been reached. No further rental payments can be made. 8.60 = Payment is denied because there is no hospital stay/surgery on file for implantation of the Durable Medical Equipment (DME) or prosthetic device. 8.61 = This supplier isn't located in your competitive bidding area, but is required to accept the same price as a supplier in your area. This supplier may not charge you more than 20% of the bid price , plus any unmet deductibles. 8.62 = This supplier didn't win a contract for furnishing this item in the competitive bidding area where you received it. This supplier isn't allowed to charge you for this item unless you signed a written notice agreeing to pay before you got the item. 8.63 = This supplier isn't located in your competitive bidding area, but is located in a different competitive bidding area. This supplier won a contract under national competitive bidding in their area. They must accept the bid price from your area as payment in full, and may not charge you more than 20% of the bid price for your area, plus any unmet deductibles. 8.64 = Monthly payments can be made for 13 months, or until the equipment is no longer needed, whichever comes first. After the 13th month, your supplier must transfer title of this equipment to you. 8.65 = Medicare will pay for medically necessary maintenance and/or servicing as needed after the end of the 13th paid rental month. 8.66 = Medicare has paid for 36 months of rental for your oxygen equipment. Your supplier must transfer title of this equipment to you. No further rental payments will be made. We will continue to pay for delivery of oxygen contents, as appropriate, and necessary maintenance of your equipment. 8.67 = Medicare has already paid for 36 months of rental for your oxygen equipment. The supplier should have transferred the title for the equipment to you. The supplier may not collect any more money from you for this equipment, and must provide you with a refund of any money you have already paid. 8.68 = Medicare will pay for you to rent oxygen for up to 36 months (or until you no longer need the equipment). After Medicare makes 36 payments, your supplier will transfer the title of the equipment to you, and you will own the equipment. 8.69 = Medicare will pay to maintain and service your oxygen equipment. This will start six months after the supplier transfers the title of the equipment to you. 8.7 = This equipment is covered only if rented. 8.70 = The Medicare-approved amount is based on the bid price for this item under the DMEPOS competitive bidding program. 8.71 = Our records show that you began using this item before the current round of competitive bidding and you decided to keep getting this item from your current supplier. The Medicare-approved amount is based on the bid price for this item. 8.72 = This item must be provided by a contract supplier under the DMEPOS competitive bidding program. You should not be billed for this item or service. You do not have to pay this amount. There are no Medicare appeal rights related to this item. 8.73 = The claim for this service was processed according to rules of the DMEPOS competitive bidding program. 8.74 = You signed an Advanced Beneficiary Notice (ABN) saying that you wanted to get this item from a non-winning supplier under the DMEPOS Competitive Bidding Program. Therefore, Medicare will not pay for this item. You must pay the supplier in full. 8.75 = Our records show that you began using this item before competitive bidding started for this item in your area. Because you decided to keep getting this item from your current supplier, this item will be paid at the standard payment amount and not at the bid price. 8.76 = This item or service is not covered because the claim shows that it was not given in a skilled nursing facility or a nursing facility. The claim for this item or service was processed according to the rules of the DMEPOS competitive bidding program. 8.78 = Medicare has paid for 36 months for your oxygen equipment. Your supplier is required to provide the oxygen equipment and related supplies, at no charge, for the remainder of the equipment's 5 year lifetime. 8.79 = Medicare has paid 36 months of rental for your oxygen equipment. The supplier may not collect any more money from you for this equipment, and must refund any money you have already paid. 8.8 = This equipment is covered only if purchased. 8.80 = Medicare will pay for rental of this equipment for 36 months (or until you no longer need the equipment). After 36 months, Medicare will continue to pay for delivery of liquid or gaseous contents, as long as it is still medically necessary. 8.81 = If the provider/supplier should have known that Medicare would not pay for the denied items or services and did not tell you in writing before providing them that Medicare probably would deny payment , you may be entitled to a refund of any amounts you paid. However, if the provider/supplier requests a review of this claim within 30 days, a refund is not required until we complete our review . If you paid for this service and do not hear anything about a refund within the next 30 days, contact your provider/ supplier. 8.9 = Payment has been reduced by the amount already paid for the rental of this equipment. 8.90 = You live in a Competitive Bidding Area. This is a Competitive Bidding item. The Medicare approved amount is based on the bid price for this item under the DMEPOS competitive bidding program. 8.91 = Our records show that you began using this item before the DMEPOS Competitive Bidding program began and you decided to keep renting this item from your current supplier. The Medicare-approved amount is based on the bid price for this item for the area where you live. 8.92 = You live in a Competitive Bidding Area and this item must be provided by a Medicare-contract supplier under the DMEPOS competitive bidding program. Medicare won't pay for this item and you shouldn't be billed for this item or service. You don't have to pay this amount. Medicare appeal rights don't apply to this item. 8.93 = Medicare only pays 36 monthly payments for your oxygen. After 36 months, the supplier is still responsible for providing you with that equipment for 5 years. You shouldn't pay any more copayments. 8.95 = Our records show that you began using this item before the DMEPOS Competitive Bidding program started for this item in your area. Because you decided to keep renting this item from your current supplier, this item will be paid at the standard payment amount and not at the bid price. 8.96 = This item or service isn't covered because the claim shows that it wasn't provided in a skilled nursing facility or nursing facility. The claim for this item or service was processed according to the rules of the DMEPOS competitive bidding program. 8.97 = Starting January 1, 2011, you may have to use certain Medicare-contracted suppliers to get certain medical equipment and supplies. Visit www.medicare.gov or call 1-800-MEDICARE for details Section 9 Failure to Furnish Information 9.1 = The information we requested was not received. 9.2 = This item or service was denied because information required to make payment was missing. 9.3 = Please ask your provider to submit a new, complete claim to us. 9.4 = This item or service was denied because information required to make payment was incorrect. 9.5 = Our records show your doctor did not order this supply or amount of supplies. 9.6 = Please ask your provider to resubmit this claim with a breakdown of the charges or services. 9.7 = We have asked your provider to resubmit the claim with the missing or correct information. 9.8 = The hospital has been asked to submit additional information, you should not be billed at this time. 9.9 = This service is not covered unless the supplier/provider files an electronic media claim (EMC). Section 96 Jurisdiction-Specific 96.10 = Go paperless, go green! If you live in CT or NY you can stop getting paper Medicare Summary Notices (MSNs) in the mail, and get Electronic MSNs (eMSNs) online instead. To sign up, go to www.mymedicare.gov or call 1-800- MEDICARE (1-800-633-4227). * See Message Notes -----------> Section 97 FISS Part A 97.xx = The entire range of 97.xx messages have been blocked off for FISS/Part A usage. Section 99 Florida-Specific 99.xx = The entire range of 99.xx messages have been blocked off for Florida usage. CLM_MASS_ADJSTMT_IND_CD_TB Claim Mass Adjustment Indicator Code Table M = Mass Adjustment (MPFS) O = Mass Adjustment (Other) CLM_PAPER_PRVDR_TB Claim Paper Claim Provider Code Table DK = Ordering Provider DN = Referring Provider DQ = Supervising Provider CLM_PWK_TB Claim Paperwork Code Table P1 = one iteration is present P2 = two iterations are present P3 = three iterations are present P4 = four iterations are present P5 = five iterations are present P6 = six iterations are present P7 = seven iterations are present P8 = eight iterations are present P9 = nine iterations are present P0 = ten iterations are present CLM_RAC_ADJSTMT_TB Recovery Audit Contractor (RAC) Adjustment Indicator Table R = RAC adjusted claim Spaces CLM_RMTNC_ADVC_TB Claim Remittance Advice Code Table M1 = X-ray not taken within the past 12 months or near enough to the start of treatment. Start: 01/01/1997 M2 = Not paid separately when the patient is an inpatient. Start: 01/01/1997 M3 = Equipment is the same or similar to equipment already being used. Start: 01/01/1997 M4 = Alert: This is the last monthly installment payment for this durable medical equipment. Start: 01/01/1997 M5 = Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed. Start: 01/01/1997 M6 = Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment. Start: 01/01/1997 M7 = No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price. Start: 01/01/1997 M8 = We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. Start: 01/01/1997 M9 = Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement. Start: 01/01/1997 | M10 = Equipment purchases are limited to the first or the tenth month of medical necessity. Start: 01/01/1997 M11 = DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code. Start: 01/01/1997 M12 = Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim. Start: 01/01/1997 M13 = Only one initial visit is covered per specialty per medical group. Start: 01/01/1997 | M14 = No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection. Start: 01/01/1997 M15 = Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. Start: 01/01/1997 M16 = Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision. Start: 01/01/1997 | Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07) M17 = Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions. Start: 01/01/1997 M18 = Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home. Start: 01/01/1997 M19 = Missing oxygen certification/ recertification. Start: 01/01/1997 M20 = Missing/incomplete/invalid HCPCS. Start: 01/01/1997 M21 = Missing/incomplete/invalid place of residence for this service/item provided in a home. Start: 01/01/1997 M22 = Missing/incomplete/invalid number of miles traveled. Start: 01/01/1997 M23 = Missing invoice. Start: 01/01/1997 M24 = Missing/incomplete/invalid number of doses per vial. Start: 01/01/1997 | M25 = The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. Start: 01/01/1997 | Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07, 11/1/10) M26 = The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice.= The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office. Start: 01/01/1997 | Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356) M27 = Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office. Start: 01/01/1997 | Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07) M28 = This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. Start: 01/01/1997 M29 = Missing operative note/report. Start: 01/01/1997 | Notes: (Modified 2/28/03, 7/1/2008) Related to N233 M30 = Missing pathology report. Start: 01/01/1997 | Notes: (Modified 8/1/04, 2/28/03) Related to N236 M31 = Missing radiology report. Start: 01/01/1997 | Notes: (Modified 8/1/04, 2/28/03) Related to N240 M32 = Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service. Start: 01/01/1997 | Notes: (Modified 4/1/07) M33 = Missing/incomplete/invalid UPIN for the ordering/referring/performing provider. Start: 01/01/1997 | Stop: 08/01/2004 Notes: Consider using M68 M34 = Claim lacks the CLIA certification number. Start: 01/01/1997 | Stop: 08/01/2004 Notes: Consider using MA120 M35 = Missing/incomplete/invalid pre- operative photos or visual field results. Start: 01/01/1997 | Stop: 02/05/2005 Notes: Consider using N178 M36 = This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase. Start: 01/01/1997 M37 = Not covered when the patient is under age 35. Start: 01/01/1997 | Notes: (Modified 3/8/11) M38 = The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay. Start: 01/01/1997 M39 = The patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. Start: 01/01/1997 | Notes: (Modified 2/1/04, 4/1/07, 11/1/09, 11/1/12) Related to N563 M40 = Claim must be assigned and must be filed by the practitioner's employer. Start: 01/01/1997 M41 = We do not pay for this as the patient has no legal obligation to pay for this. Start: 01/01/1997 M42 = The medical necessity form must be personally signed by the attending physician. Start: 01/01/1997 M43 = Payment for this service previously issued to you or another provider by another carrier/intermediary. Start: 01/01/1997 | Stop: 01/31/2004 Notes: Consider using Reason Code 23 M44 = Missing/incomplete/invalid condition code. Start: 01/01/1997 | Notes: (Modified 2/28/03) M45 = Missing/incomplete/invalid occurrence code(s). Start: 01/01/1997 | Notes: (Modified 12/2/04) Related to N299 M46 = Missing/incomplete/invalid occurrence span code(s). Start: 01/01/1997 | Notes: (Modified 12/2/04) Related to N300 M47 = Missing/incomplete/invalid internal or document control number. Start: 01/01/1997 | Notes: (Modified 2/28/03) M48 = Payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service. Start: 01/01/1997 | Stop: 01/31/2004 Notes: Consider using M97 M49 = Missing/incomplete/invalid value code(s) or amount(s). Start: 01/01/1997 | Notes: (Modified 2/28/03) M50 = Missing/incomplete/invalid revenue code(s). Start: 01/01/1997 | Notes: (Modified 2/28/03) M51 = Missing/incomplete/invalid procedure code(s). Start: 01/01/1997 | Notes: (Modified 12/2/04) Related to N301 M52 = Missing/incomplete/invalid "from" date(s) of service. Start: 01/01/1997 | Notes: (Modified 2/28/03) M53 = Missing/incomplete/invalid days or units of service. Start: 01/01/1997 | Notes: (Modified 2/28/03) M54 = Missing/incomplete/invalid total charges. Start: 01/01/1997 | M55 = We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug. Start: 01/01/1997 M56 = Missing/incomplete/invalid payer identifier. Start: 01/01/1997 | Notes: (Modified 2/28/03) M57 = Missing/incomplete/invalid provider identifier. Start: 01/01/1997 | Stop: 06/02/2005 M58 = Missing/incomplete/invalid claim information. Resubmit claim after corrections. Start: 01/01/1997 | Stop: 02/05/2005 M59 = Missing/incomplete/invalid "to" date(s) of service. Start: 01/01/1997 | Notes: (Modified 2/28/03) M60 = Missing Certificate of Medical Necessity. Start: 01/01/1997 | Notes: (Modified 8/1/04, 6/30/03) Related to N227 M61 = We cannot pay for this as the approval period for the FDA clinical trial has expired. Start: 01/01/1997 M62 = Missing/incomplete/invalid treatment authorization code. Start: 01/01/1997 | Notes: (Modified 2/28/03) M63 = We do not pay for more than one of these on the same day. Start: 01/01/1997 | Stop: 01/31/2004 Notes: Consider using M86 M64 = Missing/incomplete/invalid other diagnosis. Start: 01/01/1997 | Notes: (Modified 2/28/03) M65 = One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician. Start: 01/01/1997 M66 = Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items. Start: 01/01/1997 M67 = Missing/incomplete/invalid other procedure code(s). Start: 01/01/1997 Notes: (Modified 12/2/04) Related to N302 M68 = Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification. Start: 01/01/1997 Stop: 06/02/2005 M69 = Paid at the regular rate as you did not submit documentation to justify the modified procedure code. Start: 01/01/1997 | Notes: (Modified 2/1/04) M70 = Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item. Start: 01/01/1997 | Notes: (Modified 4/1/2007, 8/1/07) M71 = Total payment reduced due to overlap of tests billed. Start: 01/01/1997 M72 = Did not enter full 8-digit date (MM/DD/CCYY). Start: 01/01/1997 | Stop: 10/16/2003 Notes: Consider using MA52 M73 = The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components. Start: 01/01/1997 Notes: (Modified 8/1/04) M74 = This service does not qualify for a HPSA/Physician Scarcity bonus payment. Start: 01/01/1997 Notes: (Modified 12/2/04) M75 = Multiple automated multichannel tests performed on the same day combined for payment. Start: 01/01/1997 Notes: (Modified 11/5/07) M76 = Missing/incomplete/invalid diagnosis or condition. Start: 01/01/1997 Notes: (Modified 2/28/03) M77 = Missing/incomplete/invalid place of service. Start: 01/01/1997 Last Modified: 02/28/2003 Notes: (Modified 2/28/03) M78 = Missing/incomplete/invalid HCPCS modifier. Start: 01/01/1997 Stop: 05/18/2006 Notes: (Modified 2/28/03,) Consider using Reason Code 4 M79 = Missing/incomplete/invalid charge. Start: 01/01/1997 Notes: (Modified 2/28/03) M80 = Not covered when performed during the same session/date as a previously processed service for the patient. Start: 01/01/1997 Notes: (Modified 10/31/02) M81 = You are required to code to the highest level of specificity. Start: 01/01/1997 Notes: (Modified 2/1/04) M82 = Service is not covered when patient is under age 50. Start: 01/01/1997 M83 = Service is not covered unless the patient is classified as at high risk. Start: 01/01/1997 M84 = Medical code sets used must be the codes in effect at the time of service Start: 01/01/1997 Notes: (Modified 2/1/04) M85 = Subjected to review of physician evaluation and management services. Start: 01/01/1997 M86 = Service denied because payment already made for same/similar procedure within set time frame. Start: 01/01/1997 M87 = Claim/service(s) subjected to CFO-CAP prepayment review. Start: 01/01/1997 M88 = We cannot pay for laboratory tests unless billed by the laboratory that did the work. Start: 01/01/1997 Stop: 08/01/2004 Notes: Consider using Reason Code B20 M89 = Not covered more than once under age 40. Start: 01/01/1997 M90 = Not covered more than once in a 12 month period. Start: 01/01/1997 M91 = Lab procedures with different CLIA certification numbers must be billed on separate claims. Start: 01/01/1997 M92 = Services subjected to review under the Home Health Medical Review Initiative. Start: 01/01/1997 | Stop: 08/01/2004 M93 = Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment. Start: 01/01/1997 M94 = Information supplied does not support a break in therapy. A new capped rental period will not begin. Start: 01/01/1997 M95 = Services subjected to Home Health Initiative medical review/cost report audit. Start: 01/01/1997 M96 = The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only. Start: 01/01/1997 M97 = Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility. Start: 01/01/1997 M98 = Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using M99 M99 = Missing/incomplete/invalid Universal Product Number/Serial Number. Start: 01/01/1997 M100 = We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug. Start: 01/01/1997 M101 = Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using M78 M102 = Service not performed on equipment approved by the FDA for this purpose. Start: 01/01/1997 M103 = Information supplied supports a break in therapy. However, the medical info- mation we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment. Start: 01/01/1997 M104 = Information supplied supports a break in therapy. a new capped rental period will begom wieth delivery of the equipment. This is the maximum approved under the fee schedule for this item or service. Start: 01/01/1997 M105 = Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin. Start: 01/01/1997 M106 = Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service. Start: 01/01/1997 | Stop: 01/31/2004 Notes: Consider using MA 31 M107 = Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%. Start: 01/01/1997 M108 = Missing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test. Start: 01/01/1997 | Stop: 06/02/2005 M109 = We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner. Start: 01/01/1997 M110 = Missing/incomplete/invalid provider identifier for the provider from whom you purchased interpretation services. Start: 01/01/1997 | Stop: 06/02/2005 M111 = We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken. Start: 01/01/1997 M112 = Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides. Start: 01/01/1997 M113 = Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program. Start: 01/01/1997 M114 = This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these these projects, contact your local contractor. Start: 01/01/1997 M115 = This item is denied when provided to this patient by a non-contract or non- demonstration supplier. Start: 01/01/1997 M116 = Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program. Start: 01/01/1997 M117 = Not covered unless submitted via electronic claim. Start: 01/01/1997 M118 = Letter to follow containing further information. Start: 01/01/1997 Stop: 01/01/2011 M119 = Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC). Start: 01/01/1997 M120 = Missing/incomplete/invalid provider identifier for the substituting physician who furnished the service(s) under a reciprocal billing or locum tenens arrangement. Start: 01/01/1997 Stop: 06/02/2005 M121 = We pay for this service only when performed with a covered cryosurgical ablation. Start: 01/01/1997 M122 = Missing/incomplete/invalid level of subluxation. Start: 01/01/1997 M123 = Missing/incomplete/invalid name, strength, or dosage of the drug furnished. Start: 01/01/1997 M124 = Missing indication of whether the patient owns the equipment that requires the part or supply. Start: 01/01/1997 Notes: Related to N230 M125 = Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed. Start: 01/01/1997 | M126 = Missing/incomplete/invalid individual lab codes included in the test. Start: 01/01/1997 | M127 = Missing patient medical record for this service. Start: 01/01/1997 | Notes: Related to N237 M128 = Missing/incomplete/invalid date of the patient's last physician visit. Start: 01/01/1997 | Stop: 06/02/2005 M129 = Missing/incomplete/invalid indicator of x-ray availability for review. Start: 01/01/1997 M130 = Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used. Start: 01/01/1997 Notes: Related to N231 M131 = Missing physician financial relationship form. Start: 01/01/1997 Notes: Related to N239 M132 = Missing pacemaker registration form. Start: 01/01/1997 Notes: Related to N235 M133 = Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test. Start: 01/01/1997 M134 = Performed by a facility/supplier in which the provider has a financial interest. Start: 01/01/1997 M135 = Missing/incomplete/invalid plan of treatment. Start: 01/01/1997 M136 = Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician. Start: 01/01/1997 M137 = Part B coinsurance under a demonstration project or pilot program. Start: 01/01/1997 M138 = Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants. Start: 01/01/1997 M139 = Denied services exceed the coverage limit for the demonstration. Start: 01/01/1997 M140 = Service not covered until after the patient's 50th birthday, i.e., no coverage prior to the day after the 50th birthday Start: 01/01/1997 Stop: 1/30/2004 Notes: Consider using M82 M141 = Missing physician certified plan of care. Start: 01/01/1997 Notes: Related to N238 M142 = Missing American Diabetes Association Certificate of Recognition. Start: 01/01/1997 Last Modified: 02/28/2003 Notes: Related to N226 M143 = The provider must update license information with the payer. Start: 01/01/1997 | M144 = Pre-/post-operative care payment is included in the allowance for the surgery/procedure. Start: 01/01/1997 MA01 = Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late. Start: 01/01/1997 8/1/05, 4/1/07) MA02 = Alert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice. Start: 01/01/1997 MA03 = If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied, including reopened appeals if you received a revised decision. You must appeal each claim on time. Start: 01/01/1997 Stop: 10/01/2006 Last Modified: 11/18/2005 Notes: Consider using MA02 (Modified 10/31/02, 6/30/03, 8/1/05, 11/18/05) MA04 = Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible. Start: 01/01/1997 MA05 = Incorrect admission date patient status or type of bill entry on claim. Start: 01/01/1997 Stop: 10/16/2003 Notes: Consider using MA30, MA40 or MA43 MA06 = Missing/incomplete/invalid beginning and/or ending date(s). Start: 01/01/1997 Stop: 08/01/2004 Notes: Consider using MA31 MA07 = Alert: The claim information has also been forwarded to Medicaid for review. Start: 01/01/1997 MA08 = Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare. Start: 01/01/1997 MA09 = Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims. Start: 01/01/1997 MA10 = Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient. Start: 01/01/1997 MA11 = Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using M32 MA12 = You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s). Start: 01/01/1997 MA13 = Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code. Start: 01/01/1997 MA14 = Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services. Start: 01/01/1997 MA15 = Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. Start: 01/01/1997 | MA16 = The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703. Start: 01/01/1997 MA17 = We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment. Start: 01/01/1997 MA18 = Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. Start: 01/01/1997 MA19 = Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer. Start: 01/01/1997 MA20 = Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence. Start: 01/01/1997 MA21 = SSA records indicate mismatch with name and sex. Start: 01/01/1997 MA22 = Payment of less than $1.00 suppressed. Start: 01/01/1997 MA23 = Demand bill approved as result of medical review. Start: 01/01/1997 MA24 = Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period. Start: 01/01/1997 | MA25 = A patient may not elect to change a hospice provider more than once in a benefit period. Start: 01/01/1997 MA26 = Alert: Our records indicate that you were previously informed of this rule. Start: 01/01/1997 | MA27 = Missing/incomplete/invalid entitlement number or name shown on the claim. Start: 01/01/1997 | MA28 = Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice. Start: 01/01/1997 | MA29 = Missing/incomplete/invalid provider name, city, state, or zip code. Start: 01/01/1997 | Stop: 06/02/2005 MA30 = Missing/incomplete/invalid type of bill. Start: 01/01/1997 | MA31 = Missing/incomplete/invalid beginning and ending dates of the period billed. Start: 01/01/1997 | MA32 = Missing/incomplete/invalid number of covered days during the billing period. Start: 01/01/1997 | MA33 = Missing/incomplete/invalid noncovered days during the billing period. Start: 01/01/1997 | MA34 = Missing/incomplete/invalid number of coinsurance days during the billing period. Start: 01/01/1997 MA35 = Missing/incomplete/invalid number of lifetime reserve days. Start: 01/01/1997 | MA36 = Missing/incomplete/invalid patient name. Start: 01/01/1997 | MA37 = Missing/incomplete/invalid patient's address. Start: 01/01/1997 | MA38 = Missing/incomplete/invalid birth date. Start: 01/01/1997 | Stop: 06/02/2005 MA39 = Missing/incomplete/invalid gender. Start: 01/01/1997 | MA40 = Missing/incomplete/invalid admission date. Start: 01/01/1997 | MA41 = Missing/incomplete/invalid admission type. Start: 01/01/1997 | MA42 = Missing/incomplete/invalid admission source. Start: 01/01/1997 | MA43 = Missing/incomplete/invalid patient status. Start: 01/01/1997 | MA44 = Alert: No appeal rights. Adjudicative decision based on law. Start: 01/01/1997 MA45 = Alert: As previously advised, a portion or all of your payment is being held in a special account. Start: 01/01/1997 MA46 = The new information was considered but additional payment will not be issued. Start: 01/01/1997 | MA47 = Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment. Start: 01/01/1997 MA48 = Missing/incomplete/invalid name or address of responsible party or primary payer. Start: 01/01/1997 Last Modified: 02/28/2003 Notes: (Modified 2/28/03) MA49 = Missing/incomplete/invalid six-digit provider identifier for home health agency or hospice for physician(s) performing care plan oversight services. Start: 01/01/1997 Stop: 08/01/2004 Notes: Consider using MA76 MA50 = Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services. Start: 01/01/1997 | MA51 = Missing/incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory. Start: 01/01/1997 | Stop: 02/05/2005 Notes: Consider using MA120 MA52 = Missing/incomplete/invalid date. Start: 01/01/1997 | Stop: 06/02/2005 MA53 = Missing/incomplete/invalid Competitive Bidding Demonstration Project identification. Start: 01/01/1997 | MA54 = Physician certification or election consent for hospice care not received timely. Start: 01/01/1997 MA55 = Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services. Start: 01/01/1997 MA56 = Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount. Start: 01/01/1997 MA57 = Patient submitted written request to revoke his/her election for religious non-medical health care services. Start: 01/01/1997 MA58 = Missing/incomplete/invalid release of information indicator. Start: 01/01/1997 | MA59 = Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice. Start: 01/01/1997 | MA60 = Missing/incomplete/invalid patient relationship to insured. Start: 01/01/1997 | MA61 = Missing/incomplete/invalid social security number or health insurance claim number. Start: 01/01/1997 | MA62 = Alert: This is a telephone review decision. Start: 01/01/1997 | MA63 = Missing/incomplete/invalid principal diagnosis. Start: 01/01/1997 | MA64 = Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers. Start: 01/01/1997 MA65 = Missing/incomplete/invalid admitting diagnosis. Start: 01/01/1997 | MA66 = Missing/incomplete/invalid principal procedure code. Start: 01/01/1997 | Notes: Related to N303 MA67 = Correction to a prior claim. Start: 01/01/1997 MA68 = Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim. Start: 01/01/1997 | MA69 = Missing/incomplete/invalid remarks. Start: 01/01/1997 MA70 = Missing/incomplete/invalid provider representative signature. Start: 01/01/1997 | MA71 = Missing/incomplete/invalid provider representative signature date. Start: 01/01/1997 | MA72 = Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the patient on this notice. Start: 01/01/1997 | MA73 = Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care. Start: 01/01/1997 MA74 = This payment replaces an earlier payment for this claim that was either lost, damaged or returned. Start: 01/01/1997 MA75 = Missing/incomplete/invalid patient or authorized representative signature. Start: 01/01/1997 MA76 = Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services. Start: 01/01/1997 MA77 = Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice. Start: 01/01/1997 MA78 = The patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using MA59 MA79 = Billed in excess of interim rate. tart: 01/01/1997 MA80 = Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project. Start: 01/01/1997 MA81 = Missing/incomplete/invalid provider/supplier signature. Start: 01/01/1997 | MA82 = Missing/incomplete/invalid provider/supplier billing number/identifier or billing name, address, city, state, zip code, or phone number. Start: 01/01/1997 | Stop: 06/02/2005 MA83 = Did not indicate whether we are the primary or secondary payer. Start: 01/01/1997 | MA84 = Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy. Start: 01/01/1997 MA85 = Our records indicate that a primary payer exists (other than ourselves); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the PlanID when effective. Start: 01/01/1997 | Stop: 08/01/2004 Notes: Consider using MA92 MA86 = Missing/incomplete/invalid group or policy number of the insured for the primary coverage. Start: 01/01/1997 | Stop: 08/01/2004 Notes: Consider using MA92 MA87 = Missing/incomplete/invalid insured's name for the primary payer. Start: 01/01/1997 | Stop: 08/01/2004 Notes: Consider using MA92 MA88 = Missing/incomplete/invalid insured's address and/or telephone number for the primary payer. Start: 01/01/1997 | MA89 = Missing/incomplete/invalid patient's relationship to the insured for the primary payer. Start: 01/01/1997 | MA90 = Missing/incomplete/invalid employment status code for the primary insured. Start: 01/01/1997 MA91 = This determination is the result of the appeal you filed. Start: 01/01/1997 MA92 = Missing plan information for other insurance. Start: 01/01/1997 Notes: Related to N245 N245 MA93 = Non-PIP (Periodic Interim Payment) claim. Start: 01/01/1997 MA94 = Did not enter the statement "Attending physician not hospice employee" on the claim form to certify that the rendering physician is not an employee of the hospice. Start: 01/01/1997 Notes: (Reactivated 4/1/04, Modified 8/1/05) MA95 = A not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA-1500. Start: 01/01/1997 Stop: 01/01/2004 Notes: (Deactivated 2/28/2003) (Erroneous description corrected 9/2/2008) Consider using M51 MA96 = Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan. Start: 01/01/1997 MA97 = Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number. Start: 01/01/1997 | MA98 = Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary. Start: 01/01/1997 | Stop: 10/16/2003 Notes: Consider using MA97 MA99 = Missing/incomplete/invalid Medigap information. Start: 01/01/1997 | MA100 = Missing/incomplete/invalid date of current illness or symptoms Start: 01/01/1997 | MA101 = A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents. Start: 01/01/1997 Stop: 01/01/2011 Notes: Consider using N538 MA102 = Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider. Start: 01/01/1997 Stop: 08/01/2004 Notes: Consider using M68 MA103 = Hemophilia Add On. Start: 01/01/1997 MA104 = Missing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using M128 or M57 MA105 = Missing/incomplete/invalid provider number for this place of service. Start: 01/01/1997 Stop: 06/02/2005 MA106 = PIP (Periodic Interim Payment) claim. Start: 01/01/1997 MA107 = Paper claim contains more than three separate data items in field 19. Start: 01/01/1997 MA108 = Paper claim contains more than one data item in field 23. Start: 01/01/1997 MA109 = Claim processed in accordance with ambulatory surgical guidelines. Start: 01/01/1997 MA110 = Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim. Start: 01/01/1997 MA111 = Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address. Start: 01/01/1997 MA112 = Missing/incomplete/invalid group practice information. Start: 01/01/1997 MA113 = Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN. Start: 01/01/1997 MA114 = Missing/incomplete/invalid information on where the services were furnished. Start: 01/01/1997 MA115 = Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA). Start: 01/01/1997 MA116 = Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution. Start: 01/01/1997 Notes: (Reactivated 4/1/04) MA117 = This claim has been assessed a $1.00 user fee. Start: 01/01/1997 MA118 = Coinsurance and/or deductible amounts apply to a claim for services or supplies furnished to a Medicare- eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued. Start: 01/01/1997 MA119 = Provider level adjustment for late claim filing applies to this claim. Start: 01/01/1997 Stop: 05/01/2008 Notes: Consider using Reason Code B4 MA120 = Missing/incomplete/invalid CLIA certification number. Start: 01/01/1997 MA121 = Missing/incomplete/invalid x-ray date. Start: 01/01/1997 MA122 = Missing/incomplete/invalid initial treatment date. Start: 01/01/1997 MA123 = Your center was not selected to participate in this study, therefore, we cannot pay for these services. Start: 01/01/1997 MA124 = Processed for IME only. Start: 01/01/1997 Stop: 01/31/2004 Notes: Consider using Reason Code 74 MA125 = Per legislation governing this program, payment constitutes payment in full. Start: 01/01/1997 MA126 = Pancreas transplant not covered unless kidney transplant performed. Start: 10/12/2001 MA127 = Reserved for future use. Start: 10/12/2001 Stop: 06/02/2005 MA128 = Missing/incomplete/invalid FDA approval number. Start: 10/12/2001 MA129 = This provider was not certified for this procedure on this date of service. Start: 10/12/2001 Stop: 01/31/2004 Notes: Consider using MA120 and Reason Code B7 MA130 = Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. Start: 10/12/2001 MA131 = Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim. Start: 10/12/2001 MA132 = Adjustment to the pre-demonstration rate. Start: 10/12/2001 MA133 = Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay. Start: 10/12/2001 MA134 = Missing/incomplete/invalid provider number of the facility where the patient resides. Start: 10/12/2001 N1 = Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents. Start: 01/01/2000 N2 = This allowance has been made in accordance with the most appropriate course of treatment provision of the plan. Start: 01/01/2000 N3 = Missing consent form. Start: 01/01/2000 Notes: Related to N228 N4 = Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. Start: 01/01/2000 N5 = EOB received from previous payer. Claim not on file. Start: 01/01/2000 N6 = Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B. Start: 01/01/2000 N7 = Processing of this claim/service has included consideration under Major Medical provisions. Start: 01/01/2000 N8 = Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication. Start: 01/01/2000 N9 = Adjustment represents the estimated amount a previous payer may pay. Start: 01/01/2000 N10 = Payment based on the findings of a review organization/professional consult/manual adjudication/medical or dental advisor. Start: 01/01/2000 N11 = Denial reversed because of medical review. Start: 01/01/2000 N12 = Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare. Start: 01/01/2000 | N13 = Payment based on professional/technical component modifier(s). Start: 01/01/2000 N14 = Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount. Start: 01/01/2000 | Stop: 10/01/2007 Notes: Consider using Reason Code 45 N15 = Services for a newborn must be billed separately. Start: 01/01/2000 N16 = Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage. Start: 01/01/2000 N17 = Per admission deductible. Start: 01/01/2000 Stop: 08/01/2004 Notes: Consider using Reason Code 1 N18 = Payment based on the Medicare allowed amount. Start: 01/01/2000 Stop: 01/31/2004 Notes: Consider using N14 N19 = Procedure code incidental to primary procedure. Start: 01/01/2000 N20 = Service not payable with other service rendered on the same date. Start: 01/01/2000 N21 = Alert: Your line item has been separated into multiple lines to expedite handling. Start: 01/01/2000 N22 = This procedure code was added/changed because it more accurately describes the services rendered. Start: 01/01/2000 N23 = Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions. Start: 01/01/2000 N24 = Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information. Start: 01/01/2000 N25 = This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan. Start: 01/01/2000 N26 = Missing itemized bill/statement. Start: 01/01/2000 Related to N232 N27 = Missing/incomplete/invalid treatment number. Start: 01/01/2000 Last Modified: 02/28/2003 Notes: (Modified 2/28/03) N28 = Consent form requirements not fulfilled. Start: 01/01/2000 N29 = Missing documentation/orders/ notes/summary/report/chart. Start: 01/01/2000 Notes: Related to N225 N30 = Patient ineligible for this service. Start: 01/01/2000 | Last Modified: 06/30/2003 N31 = Missing/incomplete/invalid prescribing provider identifier. Start: 01/01/2000 N32 = Claim must be submitted by the provider who rendered the service. Start: 01/01/2000 N33 = No record of health check prior to initiation of treatment. Start: 01/01/2000 N34 = Incorrect claim form/format for this service. Start: 01/01/2000 N35 = Program integrity/utilization review decision. Start: 01/01/2000 N36 = Claim must meet primary payer's processing requirements before we can consider payment. Start: 01/01/2000 N37 = Missing/incomplete/invalid tooth number/letter. Start: 01/01/2000 N38 = Missing/incomplete/invalid place of service. Start: 01/01/2000 Stop: 02/05/2005 Notes: Consider using M77 N39 = Procedure code is not compatible with tooth number/letter. Start: 01/01/2000 N40 = Missing radiology film(s)/image(s). Start: 01/01/2000 Notes: Related to N242 N41 = Authorization request denied. Start: 01/01/2000 | Stop: 10/16/2003 Notes: Consider using Reason Code 39 N42 = No record of mental health assessment. Start: 01/01/2000 N43 = Bed hold or leave days exceeded. Start: 01/01/2000 N44 = Payer's share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority. Start: 01/01/2000 | Stop: 10/16/2003 Notes: Consider using Reason Code 137 N45 = Payment based on authorized amount. Start: 01/01/2000 N46 = Missing/incomplete/invalid admission hour. Start: 01/01/2000 N47 = Claim conflicts with another inpatient stay. Start: 01/01/2000 N48 = Claim information does not agree with information received from other insurance carrier. Start: 01/01/2000 N49 = Court ordered coverage information needs validation. Start: 01/01/2000 N50 = Missing/incomplete/invalid discharge information. Start: 01/01/2000 N51 = Electronic interchange agreement not on file for provider/submitter. Start: 01/01/2000 N52 = Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2000 N53 = Missing/incomplete/invalid point of pick-up address. Start: 01/01/2000 Notes: (Modified 2/28/03) N54 = Claim information is inconsistent with pre-certified/authorized services. Start: 01/01/2000 N55 = Procedures for billing with group/referring/performing providers were not followed. Start: 01/01/2000 N56 = Procedure code billed is not correct/valid for the services billed or the date of service billed. Start: 01/01/2000 N57 = Missing/incomplete/invalid prescribing date. Start: 01/01/2000 Notes: Related to N304 N58 = Missing/incomplete/invalid patient liability amount. Start: 01/01/2000 N59 = Please refer to your provider manual for additional program and provider information. Start: 01/01/2000 N60 = A valid NDC is required for payment of drug claims effective October 02. Start: 01/01/2000 Stop: 01/31/2004 Notes: Consider using M119 N61 = Rebill services on separate claims. Start: 01/01/2000 N62 = Dates of service span multiple rate periods. Resubmit separate claims. Start: 01/01/2000 N63 = Rebill services on separate claim lines. Start: 01/01/2000 N64 = The "from" and "to" dates must be different. Start: 01/01/2000 N65 = Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider. Start: 01/01/2000 N66 = Missing/incomplete/invalid documentation. Start: 01/01/2000 Stop: 02/05/2005 Notes: Consider using N29 or N225. N67 = Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim. Start: 01/01/2000 N68 = Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days. Start: 01/01/2000 N69 = PPS (Prospective Payment System) code changed by claims processing system. Start: 01/01/2000 N70 = Consolidated billing and payment applies. Start: 01/01/2000 N71 = Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims. Start: 01/01/2000 N72 = PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records. Start: 01/01/2000 N73 = A Skilled Nursing Facility is responsible for payment of outside providers who furnish these services/ supplies under arrangement to its residents. Start: 01/01/2000 Stop: 01/31/2004 Notes: Consider using MA101 or N200 N74 = Resubmit with multiple claims, each claim covering services provided in only one calendar month. Start: 01/01/2000 N75 = Missing/incomplete/invalid tooth surface information. Start: 01/01/2000 N76 = Missing/incomplete/invalid number of riders. Start: 01/01/2000 N77 = Missing/incomplete/invalid designated provider number. Start: 01/01/2000 N78 = The necessary components of the child and teen checkup (EPSDT) were not completed. Start: 01/01/2000 N79 = Service billed is not compatible with patient location information. Start: 01/01/2000 N80 = Missing/incomplete/invalid prenatal screening information. Start: 01/01/2000 | N81 = Procedure billed is not compatible with tooth surface code. Start: 01/01/2000 N82 = Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement. Start: 01/01/2000 N83 = No appeal rights. Adjudicative decision based on the provisions of a demonstration project. Start: 01/01/2000 N84 = Alert: Further installment payments are forthcoming. Start: 01/01/2000 | N85 = Alert: This is the final installment payment. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07, 8/1/07) N86 = A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered. Start: 01/01/2000 N87 = Home use of biofeedback therapy is not covered. Start: 01/01/2000 N88 = Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care. Start: 01/01/2000 N89 = Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice. Start: 01/01/2000 N90 = Covered only when performed by the attending physician. Start: 01/01/2000 N91 = Services not included in the appeal review. Start: 01/01/2000 N92 = This facility is not certified for digital mammography. Start: 01/01/2000 N93 = A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim. Start: 01/01/2000 N94 = Claim/Service denied because a more specific taxonomy code is required for adjudication. Start: 01/01/2000 N95 = This provider type/provider specialty may not bill this service. Start: 07/31/2001 N96 = Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. Start: 08/24/2001 N97 = Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded. Start: 08/24/2001 N98 = Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries. Start: 08/24/2001 N99 = Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated. Start: 08/24/2001 N100 = PPS (Prospect Payment System) code corrected during adjudication. Start: 09/14/2001 N101 = Additional information is needed in order to process this claim. Please resubmit the claim with the identification number of the provider where this service took place. The Medicare number of the site of service provider should be preceded with the letters 'HSP' and entered into item #32 on the claim form. You may bill only one site of service provider number per claim. Start: 10/31/2001 Stop: 01/31/2004 Notes: Consider uisng MA105 N102 = This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely. Start: 10/31/2001 N103 = Social Security records indicate that this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in a Federal facility, or while he or she is in State or local custody under a penal authority, unless under State or local law, the individual is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt. Start: 10/31/2001 N104 = This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. Start: 01/29/2002 N105 = This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing. Start: 01/29/2002 N106 = Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service. Start: 01/31/2002 N107 = Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services. Start: 01/31/2002 N108 = Missing/incomplete/invalid upgrade information. Start: 01/31/2002 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) N109 = This claim/service was chosen for complex review and was denied after reviewing the medical records. Start: 02/28/2002 Last Modified: 03/01/2009 Notes: (Modified 3/1/2009) N110 = This facility is not certified for film mammography. Start: 02/28/2002 N111 = No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated. Start: 02/28/2002 N112 = This claim is excluded from your electronic remittance advice. Start: 02/28/2002 N113 = Only one initial visit is covered per physician, group practice or provider. Start: 04/16/2002 N114 = During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be. Start: 05/30/2002 N115 = This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. Start: 05/30/2002 N116 = This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency's (HHA's) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care. Start: 06/30/2002 N117 = This service is paid only once in a patient's lifetime. Start: 07/30/2002 N118 = This service is not paid if billed more than once every 28 days. Start: 07/30/2002 N119 = This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days. Start: 07/30/2002 N120 = Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode. Start: 08/09/2002 N121 = Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay. Start: 09/09/2002 N122 = Add-on code cannot be billed by itself. Start: 09/12/2002 N123 = This is a split service and represents a portion of the units from the originally submitted service. Start: 09/24/2002 N124 = Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay. Start: 09/26/2002 "Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. The requirements for a refund are in Ì1834(a)(18) of the Social Security Act (and in ÌÌ1834(j)(4) and 1879(h) by cross-reference to Ì1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office." Start: 09/26/2002 N126 = Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported. Start: 10/17/2002 N127 = This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them. Start: 10/31/2007 N128 = This amount represents the prior to coverage portion of the allowance. Start: 10/31/2002 N129 = Not eligible due to the patient's age. Start: 10/31/2002 N130 = Consult plan benefit documents/guidelines for information about restrictions for this service. Start: 10/31/2002 N131 = Total payments under multiple contracts cannot exceed the allowance for this service. Start: 10/31/2002 N132 = Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified. Start: 10/31/2002 N133 = Alert: Services for predetermination and services requesting payment are being processed separately. Start: 10/31/2002 N134 = Alert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service. Start: 10/31/2002 N135 = Record fees are the patient's responsibility and limited to the specified co-payment. Start: 10/31/2002 N136 = Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548. Start: 10/31/2002 N137 = Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority. Start: 10/31/2002 N138 = Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review. Start: 10/31/2002 N139 = Alert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter. Start: 10/31/2002 N140 = Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter. Start: 10/31/2002 N141 = The patient was not residing in a long-term care facility during all or part of the service dates billed. Start: 10/31/2002 N142 = The original claim was denied. Resubmit a new claim, not a replacement claim. Start: 10/31/2002 N143 = The patient was not in a hospice program during all or part of the service dates billed. Start: 10/31/2002 N144 = The rate changed during the dates of service billed. Start: 10/31/2002 N145 = Missing/incomplete/invalid provider identifier for this place of service. Start: 10/31/2002 Stop: 06/02/2005 N146 = Missing screening document. Start: 10/31/2002 Notes: Related to N243 N147 = Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete or invalid on the assignment request. Start: 10/31/2002 N148 = Missing/incomplete/invalid date of last menstrual period. Start: 10/31/2002 N149 = Rebill all applicable services on a single claim. Start: 10/31/2002 N150 = Missing/incomplete/invalid model number. Start: 10/31/2002 N151 = Telephone contact services will not be paid until the face-to-face contact requirement has been met. Start: 10/31/2002 N152 = Missing/incomplete/invalid replacement claim information. Start: 10/31/2002 N153 = Missing/incomplete/invalid room and board rate. Start: 10/31/2002 N154 = Alert: This payment was delayed for correction of provider's mailing address. Start: 10/31/2002 N155 = Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records. Start: 10/31/2002 N156 = Alert: The patient is responsible for the difference between the approved treatment and the elective treatment. Start: 10/31/2002 N157 = Transportation to/from this destination is not covered. Start: 02/28/2003 N158 = Transportation in a vehicle other than an ambulance is not covered. Start: 02/28/2003 N159 = Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. Start: 02/28/2003 N160 = The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service. Start: 02/28/2003 N161 = This drug/service/supply is covered only when the associated service is covered. Start: 02/28/2003 N162 = Alert: Although your claim was paid, you have billed for a test/specialty not included in your laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future. Start: 02/28/2003| N163 = Medical record does not support code billed per the code definition. Start: 02/28/2003 N164 = Transportation to/from this destination is not covered. Start: 02/28/2003 Stop: 01/31/2004 Notes: Consider using N157 N165 = Transportation in a vehicle other than an ambulance is not covered. Start: 02/28/2003 Stop: 01/31/2004 Notes: Consider using N158) N166 = Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. Start: 02/28/2003 Stop: 01/31/2004 Notes: Consider using N159 N167 = Charges exceed the post-transplant coverage limit. Start: 02/28/2003 N168 = The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service. Start: 02/28/2003 Stop: 01/31/2004 Notes: Consider using N160 N169 = This drug/service/supply is covered only when the associated service is covered. Start: 02/28/2003 Stop: 01/31/2004 Notes: Consider using N161 N170 = A new/revised/renewed certificate of medical necessity is needed. Start: 02/28/2003 N171 = Payment for repair or replacement is not covered or has exceeded the purchase price. Start: 02/28/2003 N172 = The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item. Start: 02/28/2003 N173 = No qualifying hospital stay dates were provided for this episode of care. Start: 02/28/2003 N174 = This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'. Start: 02/28/2003 N175 = Missing review organization approval. Start: 02/28/2003 Notes: Related to N241 N176 = Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service. Start: 02/28/2003 N177 = Alert: We did not send this claim to patient's other insurer. They have indicated no additional payment can be made. Start: 02/28/2003 N178 = Missing pre-operative photos or visual field results. Start: 02/28/2003 Notes: Related to N244 N179 = Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information. Start: 02/28/2003 N180 = This item or service does not meet the criteria for the category under which it was billed. Start: 02/28/2003 N181 = Additional information is required from another provider involved in this service. Start: 02/28/2003 Last Modified: 12/01/2006 Notes: (Modified 12/1/06) N182 = This claim/service must be billed according to the schedule for this plan. Start: 02/28/2003 N183 = Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits. Start: 02/28/2003 N184 = Rebill technical and professional components separately. Start: 02/28/2003 N185 = Alert: Do not resubmit this claim/service. Start: 02/28/2003 N186 = Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance. Start: 02/28/2003 N187 = Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents. Start: 02/28/2003 N188 = The approved level of care does not match the procedure code submitted. Start: 02/28/2003 N189 = Alert: This service has been paid as a one-time exception to the plan's benefit restrictions. Start: 02/28/2003 N190 = Missing contract indicator. Start: 02/28/2003 Notes: Related to N229 N191 = The provider must update insurance information directly with payer. Start: 02/28/2003 N192 = Patient is a Medicaid/Qualified Medicare Beneficiary Start: 02/28/2003 N193 = Specific federal/state/local program may cover this service through another payer. Start: 02/28/2003 N194 = Technical component not paid if provider does not own the equipment used. Start: 02/25/2003 N195 = The technical component must be billed separately. Start: 02/25/2003 N196 = Alert: Patient eligible to apply for other coverage which may be primary. Start: 02/25/2003 N197 = The subscriber must update insurance information directly with payer. Start: 02/25/2003 N198 = Rendering provider must be affiliated with the pay-to provider. Start: 02/25/2003 N199 = Additional payment/recoupment approved based on payer-initiated review/audit. Start: 02/25/2003 N200 = The professional component must be billed separately. Start: 02/25/2003 N201 = A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents. Start: 02/25/2003 Stop: 01/01/2011 Notes: Consider using N538 N202 = Additional information/explanation will be sent separately Start: 06/30/2003 N203 = Missing/incomplete/invalid anesthesia time/units Start: 06/30/2003 N204 = Services under review for possible pre-existing condition. Send medical records for prior 12 months Start: 06/30/2003 N205 = Information provided was illegible Start: 06/30/2003 N206 = The supporting documentation does not match the information sent on the claim. Start: 06/30/2003 Notes: (Modified 3/6/12) N207 = Missing/incomplete/invalid weight. Start: 06/30/2003 N208 = Missing/incomplete/invalid DRG code Start: 06/30/2003 N209 = Missing/incomplete/invalid taxpayer identification number (TIN). Start: 06/30/2003 N210 = Alert: You may appeal this decision Start: 06/30/2003 N211 = Alert: You may not appeal this decision Start: 06/30/2003 N212 = Charges processed under a Point of Service benefit Start: 02/01/2004 N213 = Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information Start: 04/01/2004 N214 = Missing/incomplete/invalid history of the related initial surgical procedure(s) Start: 04/01/2004 N215 = Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination. Start: 04/01/2004 N216 = We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package Start: 04/01/2004 N217 = We pay only one site of service per provider per claim Start: 08/01/2004 N218 = You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual. Start: 08/01/2004 N219 = Payment based on previous payer's allowed amount. Start: 08/01/2004 N220 = Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute. Start: 08/01/2004 N221 = Missing Admitting History and Physical report. Start: 08/01/2004 N222 = Incomplete/invalid Admitting History and Physical report. Start: 08/01/2004 N223 = Missing documentation of benefit to the patient during initial treatment period. N224 = Incomplete/invalid documentation of benefit to the patient during initial treatment period. Start: 08/01/2004 N225 = Incomplete/invalid documentation/orders/notes/summary/ report/chart. Start: 08/01/2004 N226 = Incomplete/invalid American Diabetes Association Certificate of Recognition. Start: 08/01/2004 N227 = Incomplete/invalid Certificate of Medical Necessity. Start: 08/01/2004 N228 = Incomplete/invalid consent form. Start: 08/01/2004 N229 = Incomplete/invalid contract indicator. Start: 08/01/2004 N230 = Incomplete/invalid indication of whether the patient owns the equipment equipment that requires the part or or supply. Start: 08/01/2004 N231 = Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used. Start: 08/01/2004 N232 = Incomplete/invalid itemized bill/statement. Start: 08/01/2004 N233 = Incomplete/invalid operative note/report. Start: 08/01/2004 N234 = Incomplete/invalid oxygen certification/re-certification. Start: 08/01/2004 N235 = Incomplete/invalid pacemaker registration form. Start: 08/01/2004 N236 = Incomplete/invalid pathology report. Start: 08/01/2004 N237 = Incomplete/invalid patient medical record for this service. Start: 08/01/2004 N238 = Incomplete/invalid physician certified plan of care Start: 08/01/2004 N239 = Incomplete/invalid physician financial relationship form. Start: 08/01/2004 N240 = Incomplete/invalid radiology report. Start: 08/01/2004 N241 = Incomplete/invalid review organization approval. Start: 08/01/2004 N242 = Incomplete/invalid radiology film(s) /image(s). Start: 08/01/2004 N243 = Incomplete/invalid/not approved screening document. Start: 08/01/2004 N244 = Incomplete/invalid pre-operative photos/visual field results. Start: 08/01/2004 N245 = Incomplete/invalid plan information for other insurance Start: 08/01/2004 N246 = State regulated patient payment limitations apply to this service. Start: 12/02/2004 N247 = Missing/incomplete/invalid assistant surgeon taxonomy. Start: 12/02/2004 N248 = Missing/incomplete/invalid assistant surgeon name. Start: 12/02/2004 N249 = Missing/incomplete/invalid assistant surgeon primary identifier. Start: 12/02/2004 N250 = Missing/incomplete/invalid assistant surgeon secondary identifier. Start: 12/02/2004 N251 = Missing/incomplete/invalid attending provider taxonomy. Start: 12/02/2004 N252 = Missing/incomplete/invalid attending provider name. Start: 12/02/2004 N253 = Missing/incomplete/invalid attending provider primary identifier. Start: 12/02/2004 N254 = Missing/incomplete/invalid attending provider secondary identifier. Start: 12/02/2004 N255 = Missing/incomplete/invalid billing provider taxonomy. Start: 12/02/2004 N256 = Missing/incomplete/invalid billing provider/supplier name. Start: 12/02/2004 N257 = Missing/incomplete/invalid billing provider/supplier primary identifier. Start: 12/02/2004 N258 = Missing/incomplete/invalid billing provider/supplier address. Start: 12/02/2004 N259 = Missing/incomplete/invalid billing provider/supplier secondary identifier. Start: 12/02/2004 N260 = Missing/incomplete/invalid billing provider/supplier contact information. Start: 12/02/2004 N261 = Missing/incomplete/invalid operating provider name. Start: 12/02/2004 N262 = Missing/incomplete/invalid operating provider primary identifier. Start: 12/02/2004 N263 = Missing/incomplete/invalid operating provider secondary identifier. Start: 12/02/2004 N264 = Missing/incomplete/invalid ordering provider name. Start: 12/02/2004 N265 = Missing/incomplete/invalid ordering provider primary identifier. Start: 12/02/2004 N266 = Missing/incomplete/invalid ordering provider address. Start: 12/02/2004 N267 = Missing/incomplete/invalid ordering provider secondary identifier. Start: 12/02/2004 N268 = Missing/incomplete/invalid ordering provider contact information. Start: 12/02/2004 N269 = Missing/incomplete/invalid other provider name. Start: 12/02/2004 N270 = Missing/incomplete/invalid other provider primary identifier. Start: 12/02/2004 N271 = Missing/incomplete/invalid other provider secondary identifier. Start: 12/02/2004 N272 = Missing/incomplete/invalid other payer attending provider identifier. Start: 12/02/2004 N273 = Missing/incomplete/invalid other payer operating provider identifier. Start: 12/02/2004 N274 = Missing/incomplete/invalid other payer other provider identifier. Start: 12/02/2004 N275 = Missing/incomplete/invalid other payer purchased service provider identifier. Start: 12/02/2004 N276 = Missing/incomplete/invalid other payer referring provider identifier. Start: 12/02/2004 N277 = Missing/incomplete/invalid other payer rendering provider identifier. Start: 12/02/2004 N278 = Missing/incomplete/invalid other payer service facility provider identifier. Start: 12/02/2004 N279 = Missing/incomplete/invalid pay-to provider name. Start: 12/02/2004 N280 = Missing/incomplete/invalid pay-to provider primary identifier. Start: 12/02/2004 N281 = Missing/incomplete/invalid pay-to provider address. Start: 12/02/2004 N282 = Missing/incomplete/invalid pay-to provider secondary identifier. Start: 12/02/2004 N283 = Missing/incomplete/invalid purchased service provider identifier. Start: 12/02/2004 N284 = Missing/incomplete/invalid referring provider taxonomy. Start: 12/02/2004 N285 = Missing/incomplete/invalid referring provider name. Start: 12/02/2004 N286 = Missing/incomplete/invalid referring provider primary identifier. Start: 12/02/2004 N287 = Missing/incomplete/invalid referring provider secondary identifier. Start: 12/02/2004 N288 = Missing/incomplete/invalid rendering provider taxonomy. Start: 12/02/2004 N289 = Missing/incomplete/invalid rendering provider name. Start: 12/02/2004 N290 = Missing/incomplete/invalid rendering provider primary identifier. Start: 12/02/2004 N291 = Missing/incomplete/invalid rendering provider secondary identifier. Start: 12/02/2004 N292 = Missing/incomplete/invalid service facility name. Start: 12/02/2004 N293 = Missing/incomplete/invalid service facility primary identifier. Start: 12/02/2004 N294 = Missing/incomplete/invalid service facility primary address. Start: 12/02/2004 N295 = Missing/incomplete/invalid service facility secondary identifier. Start: 12/02/2004 N296 = Missing/incomplete/invalid supervising provider name. Start: 12/02/2004 N297 = Missing/incomplete/invalid supervising provider primary identifier. Start: 12/02/2004 N298 = Missing/incomplete/invalid supervising provider secondary identifier. Start: 12/02/2004 N299 = Missing/incomplete/invalid occurrence date(s). Start: 12/02/2004 N300 = Missing/incomplete/invalid occurrence span date(s). Start: 12/02/2004 N301 = Missing/incomplete/invalid procedure date(s). Start: 12/02/2004 N302 = Missing/incomplete/invalid other procedure date(s). Start: 12/02/2004 N303 = Missing/incomplete/invalid principal procedure date. Start: 12/02/2004 N304 = Missing/incomplete/invalid dispensed date. Start: 12/02/2004 N305 = Missing/incomplete/invalid accident date. Start: 12/02/2004 N306 = Missing/incomplete/invalid acute manifestation date. Start: 12/02/2004 N307 = Missing/incomplete/invalid adjudication or payment date. Start: 12/02/2004 N308 = Missing/incomplete/invalid appliance placement date. Start: 12/02/2004 N309 = Missing/incomplete/invalid assessment date. Start: 12/02/2004 N310 = Missing/incomplete/invalid assumed or relinquished care date. Start: 12/02/2004 N311 = Missing/incomplete/invalid authorized to return to work date. Start: 12/02/2004 N312 = Missing/incomplete/invalid begin therapy date. Start: 12/02/2004 N313 = Missing/incomplete/invalid certification revision date. Start: 12/02/2004 N314 = Missing/incomplete/invalid diagnosis date. Start: 12/02/2004 N315 = Missing/incomplete/invalid disability from date. Start: 12/02/2004 N316 = Missing/incomplete/invalid disability to date. Start: 12/02/2004 N317 = Missing/incomplete/invalid discharge hour. Start: 12/02/2004 N318 = Missing/incomplete/invalid discharge or end of care date. Start: 12/02/2004 N319 = Missing/incomplete/invalid hearing or vision prescription date. Start: 12/02/2004 N320 = Missing/incomplete/invalid Home Health Certification Period. Start: 12/02/2004 N321 = Missing/incomplete/invalid last admission period. Start: 12/02/2004 N322 = Missing/incomplete/invalid last certification date. Start: 12/02/2004 N323 = Missing/incomplete/invalid last contact date. Start: 12/02/2004 N324 = Missing/incomplete/invalid last seen/visit date. Start: 12/02/2004 N325 = Missing/incomplete/invalid last worked date. Start: 12/02/2004 N326 = Missing/incomplete/invalid last x-ray date. Start: 12/02/2004 N327 = Missing/incomplete/invalid other insured birth date. Start: 12/02/2004 N328 = Missing/incomplete/invalid Oxygen Saturation Test date. Start: 12/02/2004 N329 = Missing/incomplete/invalid patient birth date Start: 12/02/2004 N330 = Missing/incomplete/invalid patient death date. Start: 12/02/2004 N331 = Missing/incomplete/invalid physician order date. Start: 12/02/2004 N332 = Missing/incomplete/invalid prior hospital discharge date. Start: 12/02/2004 N333 = Missing/incomplete/invalid prior placement date. Start: 12/02/2004 N334 = Missing/incomplete/invalid re- evaluation date Start: 12/02/2004 N335 = Missing/incomplete/invalid referral date. Start: 12/02/2004 N336 = Missing/incomplete/invalid replacement date. Start: 12/02/2004 N337 = Missing/incomplete/invalid secondary diagnosis date. Start: 12/02/2004 N338 = Missing/incomplete/invalid shipped date. Start: 12/02/2004 N339 = Missing/incomplete/invalid similar illness or symptom date. Start: 12/02/2004 N340 = Missing/incomplete/invalid subscriber birth date. Start: 12/02/2004 N341 = Missing/incomplete/invalid surgery date. Start: 12/02/2004 N342 = Missing/incomplete/invalid test performed date. Start: 12/02/2004 N343 = Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date. Start: 12/02/2004 N344 = Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date. Start: 12/02/2004 N345 = Date range not valid with units submitted. Start: 03/30/2005 N346 = Missing/incomplete/invalid oral cavity designation code. Start: 03/30/2005 N347 = Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer. Start: 03/30/2005 N348 = You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier. Start: 08/01/2005 N349 = The administration method and drug must be reported to adjudicate this service. Start: 08/01/2005 N350 = Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure. Start: 08/01/2005 N351 = Service date outside of the approved treatment plan service dates. Start: 08/01/2005 N352 = Alert: There are no scheduled payments for this service. Submit a claim for each patient visit. Start: 08/01/2005 N353 = Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim. Start: 08/01/2005 N354 = Incomplete/invalid invoice Start: 08/01/2005 "Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position. If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision. The law also permits you to request an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination. The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days" Start: 08/01/2005 N356 = Not covered when performed with, or subsequent to, a non-covered service. Start: 08/01/2005 N357 = Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met. Start: 11/18/2005 N358 = Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted. Start: 11/18/2005 N359 = Missing/incomplete/invalid height. Start: 11/18/2005 N360 = Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim. Start: 11/18/2005 N361 = Payment adjusted based on multiple diagnostic imaging procedure rules Start: 11/18/2005 Stop: 10/01/2007 Notes: (Modified 12/1/06) Consider using Reason Code 59 N362 = The number of Days or Units of Service exceeds our acceptable maximum. Start: 11/18/2005 N363 = Alert: in the near future we are implementing new policies/procedures that would affect this determination. Start: 11/18/2005 N364 = Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts. Start: 11/18/2005 N365 = This procedure code is not payable. It is for reporting/information purposes only. Start: 04/01/2006 N366 = Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice. Start: 04/01/2006 N367 = Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account. Start: 04/01/2006 Last Modified: 07/01/2008 N368 = You must appeal the determination of the previously adjudicated claim. Start: 04/01/2006 N369 = Alert: Although this claim has been processed, it is deficient according to state legislation/regulation. Start: 04/01/2006 N370 = Billing exceeds the rental months covered/approved by the payer. Start: 08/01/2006 N371 = Alert: title of this equipment must be transferred to the patient. Start: 08/01/2006 N372 = Only reasonable and necessary maintenance/service charges are covered. Start: 08/01/2006 N373 = It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf. Start: 12/01/2006 N374 = Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required. Start: 12/01/2006 N375 = Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility. Start: 12/01/2006 N376 = Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE. Start: 12/01/2006 N377 = Payment based on a processed replacement claim. Start: 12/01/2006 N378 = Missing/incomplete/invalid prescription quantity. Start: 12/01/2006 N379 = Claim level information does not match line level information. Start: 12/01/2006 N380 = The original claim has been processed, submit a corrected claim. Start: 04/01/2007 N381 = Consult our contractual agreement for restrictions/billing/payment information related to these charges. Start: 04/01/2007 N382 = Missing/incomplete/invalid patient identifier. Start: 04/01/2007 N383 = Not covered when deemed cosmetic. Start: 04/01/2007 Last Modified: 03/08/2011 Notes: (Modified 3/8/11) N384 = Records indicate that the referenced body part/tooth has been removed in a previous procedure. Start: 04/01/2007 N385 = Notification of admission was not timely according to published plan procedures. Start: 04/01/2007 N386 = This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. Start: 04/01/2007 N387 = Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. Start: 04/01/2007 N388 = Missing/incomplete/invalid prescription number. Start: 08/01/2007 N389 = Duplicate prescription number submitted. Start: 08/01/2007 N390 = This service/report cannot be billed separately. Start: 08/01/2007 N391 = Missing emergency department records. Start: 08/01/2007 N392 = Incomplete/invalid emergency department records. Start: 08/01/2007 N393 = Missing progress notes/report. Start: 08/01/2007 N394 = Incomplete/invalid progress notes/report. Start: 08/01/2007 N395 = Missing laboratory report. Start: 08/01/2007 N396 = Incomplete/invalid laboratory report. Start: 08/01/2007 N397 = Benefits are not available for incomplete service(s)/undelivered item(s). Start: 08/01/2007 N398 = Missing elective consent form. Start: 08/01/2007 N399 = Incomplete/invalid elective consent form. Start: 08/01/2007 N400 = Alert: Electronically enabled providers should submit claims electronically. Start: 08/01/2007 N401 = Missing periodontal charting. Start: 08/01/2007 N402 = Incomplete/invalid periodontal charting. Start: 08/01/2007 N403 = Missing facility certification. Start: 08/01/2007 N404 = Incomplete/invalid facility certification. Start: 08/01/2007 N405 = This service is only covered when the donor's insurer(s) do not provide coverage for the service. Start: 08/01/2007 N406 = This service is only covered when the recipient's insurer(s) do not provide coverage for the service. Start: 08/01/2007 N407 = You are not an approved submitter for this transmission format. Start: 08/01/2007 N408 = This payer does not cover deductibles assessed by a previous payer. Start: 08/01/2007 N409 = This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident. Start: 08/01/2007 N410 = Not covered unless the prescription changes. Start: 08/01/2007 N411 = This service is allowed one time in a 6-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N412 = This service is allowed 2 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N413 = This service is allowed 2 times in a benefit year. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N414 = This service is allowed 4 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N415 = This service is allowed 1 time in an 18-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N416 = This service is allowed 1 time in a 3-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N417 = This service is allowed 1 time in a 5-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.) Start: 08/01/2007 Stop: 02/01/2009 N418 = Misrouted claim. See the payer's claim submission instructions. Start: 08/01/2007 N419 = Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change. Start: 08/01/2007 N420 = Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery. Start: 08/01/2007 N421 = Claim payment was the result of a payer's retroactive adjustment due to a review organization decision. Start: 08/01/2007 N422 = Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program. Start: 08/01/2007 N423 = Claim payment was the result of a payer's retroactive adjustment due to a non standard program. Start: 08/01/2007 N424 = Patient does not reside in the geographic area required for this type of payment. Start: 08/01/2007 N425 = Statutorily excluded service(s). Start: 08/01/2007 N426 = No coverage when self-administered. Start: 08/01/2007 N427 = Payment for eyeglasses or contact lenses can be made only after cataract surgery. Start: 08/01/2007 N428 = Not covered when performed in this place of surgery. Start: 08/01/2007 N429 = Not covered when considered routine. Start: 08/01/2007 N430 = Procedure code is inconsistent with the units billed. Start: 11/05/2007 N431 = Not covered with this procedure. Start: 11/05/2007 N432 = Adjustment based on a Recovery Audit. Start: 11/05/2007 N433 = Resubmit this claim using only your National Provider Identifier (NPI) Start: 02/29/2008 N434 = Missing/Incomplete/Invalid Present on Admission indicator. Start: 07/01/2008 N435 = Exceeds number/frequency approved /allowed within time period without support documentation. Start: 07/01/2008 N436 = The injury claim has not been accepted and a mandatory medical reimbursement has been made. Start: 07/01/2008 N437 = Alert: If the injury claim is accepted, these charges will be reconsidered. Start: 07/01/2008 N438 = This jurisdiction only accepts paper claims Start: 07/01/2008 N439 = Missing anesthesia physical status report/indicators. Start: 07/01/2008 N440 = Incomplete/invalid anesthesia physical status report/indicators. Start: 07/01/2008 N441 = This missed appointment is not covered. Start: 07/01/2008 N442 = Payment based on an alternate fee schedule. Start: 07/01/2008 N443 = Missing/incomplete/invalid total time or begin/end time. Start: 07/01/2008 N444 = Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation. Start: 07/01/2008 N445 = Missing document for actual cost or paid amount. Start: 07/01/2008 N446 = Incomplete/invalid document for actual cost or paid amount. Start: 07/01/2008 N447 = Payment is based on a generic equivalent as required documentation was not provided. Start: 07/01/2008 N448 = This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement Start: 07/01/2008 N449 = Payment based on a comparable drug/service/supply. Start: 07/01/2008 N450 = Covered only when performed by the primary treating physician or the designee. Start: 07/01/2008 N451 = Missing Admission Summary Report. Start: 07/01/2008 N452 = Incomplete/invalid Admission Summary Report. Start: 07/01/2008 N453 = Missing Consultation Report. Start: 07/01/2008 N454 = Incomplete/invalid Consultation Report. Start: 07/01/2008 N455 = Missing Physician Order. Start: 07/01/2008 N456 = Incomplete/invalid Physician Order. Start: 07/01/2008 N457 = Missing Diagnostic Report. Start: 07/01/2008 N458 = Incomplete/invalid Diagnostic Report. Start: 07/01/2008 N459 = Missing Discharge Summary. Start: 07/01/2008 N460 = Incomplete/invalid Discharge Summary. Start: 07/01/2008 N461 = Missing Nursing Notes. Start: 07/01/2008 N462 = Incomplete/invalid Nursing Notes. Start: 07/01/2008 N463 = Missing support data for claim. Start: 07/01/2008 N464 = Incomplete/invalid support data for claim. Start: 07/01/2008 N465 = Missing Physical Therapy Notes/Report. Start: 07/01/2008 N466 = Incomplete/invalid Physical Therapy Notes/Report. Start: 07/01/2008 N467 = Missing Report of Tests and Analysis Report. Start: 07/01/2008 N468 = Incomplete/invalid Report of Tests and Analysis Report. Start: 07/01/2008 N469 = Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Start: 07/01/2008 N470 = This payment will complete the mandatory medical reimbursement limit. Start: 07/01/2008 N471 = Missing/incomplete/invalid HIPPS Rate Code. Start: 07/01/2008 N472 = Payment for this service has been issued to another provider. Start: 07/01/2008 N473 = Missing certification. Start: 07/01/2008 N474 = Incomplete/invalid certification Start: 07/01/2008 N475 = Missing completed referral form. Start: 07/01/2008 N476 = Incomplete/invalid completed referral form Start: 07/01/2008 N477 = Missing Dental Models. Start: 07/01/2008 N478 = Incomplete/invalid Dental Models Start: 07/01/2008 N479 = Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Start: 07/01/2008 N480 = Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Start: 07/01/2008 N481 = Missing Models. Start: 07/01/2008 N482 = Incomplete/invalid Models Start: 07/01/2008 N483 = Missing Periodontal Charts. Start: 07/01/2008 N484 = Incomplete/invalid Periodontal Charts Start: 07/01/2008 N485 = Missing Physical Therapy Certification. Start: 07/01/2008 N486 = Incomplete/invalid Physical Therapy Certification. Start: 07/01/2008 N487 = Missing Prosthetics or Orthotics Certification. Start: 07/01/2008 N488 = Incomplete/invalid Prosthetics or Orthotics Certification Start: 07/01/2008 N489 = Missing referral form. Start: 07/01/2008 N490 = Incomplete/invalid referral form Start: 07/01/2008 N491 = Missing/Incomplete/Invalid Exclusionary Rider Condition. Start: 07/01/2008 N492 = Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge. Start: 07/01/2008 N493 = Missing Doctor First Report of Injury. Start: 07/01/2008 N494 = Incomplete/invalid Doctor First Report of Injury. Start: 07/01/2008 N495 = Missing Supplemental Medical Report. Start: 07/01/2008 N496 = Incomplete/invalid Supplemental Medical Report. Start: 07/01/2008 N497 = Missing Medical Permanent Impairment or Disability Report. Start: 07/01/2008 N498 = Incomplete/invalid Medical Permanent Impairment or Disability Report. Start: 07/01/2008 N499 = Missing Medical Legal Report. Start: 07/01/2008 N500 = Incomplete/invalid Medical Legal Report. Start: 07/01/2008 N501 = Missing Vocational Report. Start: 07/01/2008 N502 = Incomplete/invalid Vocational Report. Start: 07/01/2008 N503 = Missing Work Status Report. Start: 07/01/2008 N504 = Incomplete/invalid Work Status Report. Start: 07/01/2008 N505 = Alert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time. Start: 11/01/2008 N506 = Alert: This is an estimate of the member's liability based on the information available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment. Start: 11/01/2008 N507 = Plan distance requirements have not been met. Start: 11/01/2008 N508 = Alert: This real time claim adjudication response represents the the member responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions. Start: 11/01/2008 N509 = Alert: A current inquiry shows the member's Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing. Start: 11/01/2008 N510 = Alert: A current inquiry shows the members Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing. Start: 11/01/2008 N511 = Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time. Start: 11/01/2008 N512 = Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication. Start: 11/01/2008 N513 = Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication. Start: 11/01/2008 N514 = Consult plan benefit documents/guidelines for information about restrictions for this service. Start: 11/01/2008 Stop: 01/01/2011 Notes: Consider using N130 N515 = Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead) Start: 11/01/2008 Stop: 10/1/2009 N516 = Records indicate a mismatch between the submitted NPI and EIN. Start: 03/01/2009 N517 = Resubmit a new claim with the requested information. Start: 03/01/2009 N518 = No separate payment for accessories when furnished for use with oxygen equipment. Start: 03/01/2009 N519 = Invalid combination of HCPCS modifiers. Start: 07/01/2009 N520 = Alert: Payment made from a Consumer Spending Account. Start: 07/01/2009 N521 = Mismatch between the submitted provider information and the provider information stored in our system. Start: 11/01/2009 N522 = Duplicate of a claim processed, or to be processed, as a crossover claim. Start: 11/01/2009 N523 = The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid. Start: 03/01/2010 N524 = Based on policy this payment constitutes payment in full. Start: 03/01/2010 N525 = These services are not covered when performed within the global period of another service. Start: 03/01/2010 N526 = Not qualified for recovery based on employer size. Start: 03/01/2010 N527 = We processed this claim as the primary payer prior to receiving the recovery demand. Start: 03/01/2010 N528 = Patient is entitled to benefits for Institutional Services only. Start: 03/01/2010 N529 = Patient is entitled to benefits for Professional Services only. Start: 03/01/2010 N530 = Not Qualified for Recovery based on enrollment information. Start: 03/01/2010 | N531 = Not qualified for recovery based on direct payment of premium. Start: 03/01/2010 N532 = Not qualified for recovery based on disability and working status. Start: 03/01/2010 N533 = Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan. Start: 07/01/2010 N534 = This is an individual policy, the employer does not participate in plan sponsorship. Start: 07/01/2010 N535 = Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service. Start: 07/01/2010 N536 = We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us. Start: 07/01/2010 N537 = We have examined claims history and no records of the services have been found. Start: 07/01/2010 N538 = A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents. Start: 07/01/2010 N539 = Alert: We processed appeals/waiver requests on your behalf and that request has been denied. Start: 07/01/2010 N540 = Payment adjusted based on the interrupted stay policy. Start: 11/01/2010 N541 = Mismatch between the submitted insurance type code and the information stored in our system. Start: 11/01/2010 N542 = Missing income verification. Start: 03/08/2011 N543 = Incomplete/invalid income verification Start: 03/08/2011 N544 = Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future. Start: 07/01/2011 N545 = Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program. Start: 07/01/2011 N546 = Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program. Start: 07/01/2011 N547 = A refund request (Frequency Type Code 8) was processed previously. Start: 03/06/2012 N548 = Alert: Patient's calendar year deductible has been met. Start: 03/06/2012 N549 = Alert: Patient's calendar year out-of- pocket maximum has been met. Start: 03/06/2012 N550 = Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future. Start: 03/06/2012 N551 = Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program. Start: 03/06/2012 N552 = Payment adjusted to reverse a previous withhold/bonus amount. Start: 03/06/2012 N553 = Payment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status change. Start: 03/06/2012 Stop: 11/1/2012 N554 = Missing/Incomplete/Invalid Family Planning Indicator Start: 07/01/2012 N555 = Missing medication list. Start: 07/01/2012 N556 = Incomplete/invalid medication list. Start: 07/01/2012 N557 = This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected. Start: 07/01/2012 N558 = This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received. Start: 07/01/2012 N559 = This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located. Start: 07/01/2012 N560 = The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received. Start: 11/01/2012 N561 = The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission. Start: 11/01/2012 N562 = The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment. Start: 11/01/2012 N563 = Missing required provider/supplier issuance of advance patient notice of non-coverage. The patient is not liable for payment for this service. Start: 11/01/2012 Notes: Related to M39 N564 = Patient did not meet the inclusion criteria for the demonstration project or pilot program. Start: 11/01/2012 N565 = Alert: This procedure code requires a modifier. Future claims containing this procedure code must include an appropriate modifier for the claim to be processed. Start: 11/01/2012 N566 = Alert: This procedure code requires functional reporting. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed. Start: 11/01/2012 CMS_PRVDR_SPCLTY_TB CMS Provider Specialty Table 00 = Carrier wide 01 = General practice 02 = General surgery 03 = Allergy/immunology 04 = Otolaryngology 05 = Anesthesiology 06 = Cardiology 07 = Dermatology 08 = Family practice 09 = Interventional Pain Management (IPM) (eff. 4/1/03) 09 = Gynecology (osteopaths only) (discontinued 5/92 use code 16) 10 = Gastroenterology 11 = Internal medicine 12 = Osteopathic manipulative therapy 13 = Neurology 14 = Neurosurgery 15 = Speech Language Pathologists 15 = Obstetrics (osteopaths only) (discontinued 5/92 use code 16) 16 = Obstetrics/gynecology 17 = Hospice and Palliative Care 17 = Ophthalmology, otology, laryngology, rhinology (osteopaths only) (discontinued 5/92 use codes 18 or 04 depending on percentage of practice) 18 = Ophthalmology 19 = Oral surgery (dentists only) 20 = Orthopedic surgery 21 = Cardiac Electrophysiology 21 = Pathologic anatomy, clinical pathology (osteopaths only) (discontinued 5/92 use code 22) 22 = Pathology 23 = Sports medicine 23 = Peripheral vascular disease, medical or surgical (osteopaths only) (discontinued 5/92 use code 76) 24 = Plastic and reconstructive surgery 25 = Physical medicine and rehabilitation 26 = Psychiatry 27 = Geriatric Psychiatry Colorectal Surgery 27 = Psychiatry, neurology (osteopaths only) (discontinued 5/92 use code 86) 28 = Colorectal surgery (formerly proctology) 29 = Pulmonary disease 30 = Diagnostic radiology 31 = Intensive Cardiac Rehabilitation 31 = Roentgenology, radiology (osteopaths only) (discontinued 5/92 use code 30) 32 = Anesthesiologist Assistants (eff. 4/1/03--previously grouped with Certified Registered Nurse Anesthetists (CRNA)) 32 = Radiation therapy (osteopaths only) (discontinued 5/92 use code 92) 33 = Thoracic surgery 34 = Urology 35 = Chiropractic 36 = Nuclear medicine 37 = Pediatric medicine 38 = Geriatric medicine 39 = Nephrology 40 = Hand surgery 41 = Optometry (revised 10/93 to mean optometrist) 42 = Certified nurse midwife (eff 1/87) 43 = CRNA (eff. 1/87) (Anesthesiologist Assistants were removed from this specialty 4/1/03) 44 = Infectious disease 45 = Mammography screening center 46 = Endocrinology (eff 5/92) 47 = Independent Diagnostic Testing Facility (IDTF) (eff. 6/98) 48 = Podiatry 49 = Ambulatory surgical center (formerly miscellaneous) 50 = Nurse practitioner 51 = Medical supply company with certified orthotist (certified by American Board for Certification in Prosthetics And Orthotics) 52 = Medical supply company with certified prosthetist (certified by American Board for Certification In Prosthetics And Orthotics) 53 = Medical supply company with certified prosthetist-orthotist (certified by American Board for Certification in Prosthetics and Orthotics) 54 = Medical supply company not included in 51, 52, or 53. (Revised 10/93 to mean medical supply company for DMERC) 55 = Individual certified orthotist 56 = Individual certified prosthetist 57 = Individual certified prosthetist-orthotist 58 = Individuals not included in 55, 56, or 57, (revised 10/93 to mean medical supply company with registered pharmacist) 59 = Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc. 60 = Public health or welfare agencies (federal, state, and local) 61 = Voluntary health or charitable agencies (e.g. National Cancer Society, National Heart Association, Catholic Charities) 62 = Psychologist (billing independently) 63 = Portable X-ray supplier 64 = Audiologist (billing independently) 65 = Physical therapist (private practice added 4/1/03) (independently practicing removed 4/1/03) 66 = Rheumatology (eff 5/92) Note: during 93/94 DMERC also used this to mean medical supply company with respiratory therapist 67 = Occupational therapist (private practice added 4/1/03) (independently practicing removed 4/1/03) 68 = Clinical psychologist 69 = Clinical laboratory (billing independently) 70 = Multispecialty clinic or group practice 71 = Registered Dietician/Nutrition Professional (eff. 1/1/02) 72 = Pain Management (eff. 1/1/02) 73 = Mass Immunization Roster Biller (eff. 4/1/03) 74 = Radiation Therapy Centers (added to differentiate them from Independent Diagnostic Testing Facilities (IDTF --eff. 4/1/03) 74 = Occupational therapy (GPPP) (not to be assigned after 5/92) 75 = Slide Preparation Facilities (added to differentiate them from Independent Diagnostic Testing Facilites (IDTFs -- eff. 4/1/03) 75 = Other medical care (GPPP) (not to assigned after 5/92) 76 = Peripheral vascular disease (eff 5/92) 77 = Vascular surgery (eff 5/92) 78 = Cardiac surgery (eff 5/92) 79 = Addiction medicine (eff 5/92) 80 = Licensed clinical social worker 81 = Critical care (intensivists) (eff 5/92) 82 = Hematology (eff 5/92) 83 = Hematology/oncology (eff 5/92) 84 = Preventive medicine (eff 5/92) 85 = Maxillofacial surgery (eff 5/92) 86 = Neuropsychiatry (eff 5/92) 87 = All other suppliers (e.g. drug and department stores) (note: DMERC used 87 to mean department store from 10/93 through 9/94; recoded eff 10/94 to A7; NCH cross-walked DMERC reported 87 to A7. 88 = Unknown supplier/provider specialty (note: DMERC used 87 to mean grocery store from 10/93 - 9/94; recoded eff 10/94 to A8; NCH cross-walked DMERC reported 88 to A8. 89 = Certified clinical nurse specialist 90 = Medical oncology (eff 5/92) 91 = Surgical oncology (eff 5/92) 92 = Radiation oncology (eff 5/92) 93 = Emergency medicine (eff 5/92) 94 = Interventional radiology (eff 5/92) 95 = Competative Acquisition Program (CAP) Vendor (eff. 07/01/06). Prior to 07/01/06, known as Independent physiological laboratory (eff. 5/92) 96 = Optician (eff 10/93) 97 = Physician assistant (eff 5/92) 98 = Gynecologist/oncologist (eff 10/94) 99 = Unknown physician specialty A0 = Hospital (eff 10/93) (DMERCs only) A1 = SNF (eff 10/93) (DMERCs only) A2 = Intermediate care nursing facility (eff 10/93) (DMERCs only) A3 = Nursing facility, other (eff 10/93) (DMERCs only) A4 = HHA (eff 10/93) (DMERCs only) A5 = Pharmacy (eff 10/93) (DMERCs only) A6 = Medical supply company with respiratory therapist (eff 10/93) (DMERCs only) A7 = Department store (for DMERC use: eff 10/94, but cross-walked from code 87 eff 10/93) A8 = Grocery store (for DMERC use: eff 10/94, but cross-walked from code 88 eff 10/93) A9 = Indian Health Service (IHS), tribe and tribal organizations (non-hospital or non-hospital based facilities. DMERCs shall process claims submitted by IHS, tribe and non-tribal organizations for DMEPOS and drugs covered by the DMERCs. (eff. 1/2005) B1 = Supplier of oxygen and/or oxygen related equipment (eff. 10/2/07) B2 = Pedorthic Personnel (eff. 10/2/07) B3 = Medical Supply Company with Pedorthic Personnel (eff. 10/2/07) B4 = Rehabilitation Agency (eff. 10/2/07) B5 = Ocularist C0 = Sleep medicine C1 = Centralized Flu C4 = Non-Provider Convener Participants in the BPCI Advanced Model (eff. 7/2019) C5 = Dentist (eff. 7/2016) D5 = Opiod Treatment Progrm (eff. 1/2020) CMS_TYPE_SRVC_TB CMS Type of Service Table 1 = Medical care 2 = Surgery 3 = Consultation 4 = Diagnostic radiology 5 = Diagnostic laboratory 6 = Therapeutic radiology 7 = Anesthesia 8 = Assistant at surgery 9 = Other medical items or services 0 = Whole blood only eff 01/96, whole blood or packed red cells before 01/96 A = Used durable medical equipment (DME) B = High risk screening mammography (obsolete 1/1/98) C = Low risk screening mammography (obsolete 1/1/98) D = Ambulance (eff 04/95) E = Enteral/parenteral nutrients/supplies (eff 04/95) F = Ambulatory surgical center (facility usage for surgical services) G = Immunosuppressive drugs H = Hospice services (discontinued 01/95) I = Purchase of DME (installment basis) (discontinued 04/95) J = Diabetic shoes (eff 04/95) K = Hearing items and services (eff 04/95) L = ESRD supplies (eff 04/95) (renal supplier in the home before 04/95) M = Monthly capitation payment for dialysis N = Kidney donor P = Lump sum purchase of DME, prosthetics, orthotics Q = Vision items or services R = Rental of DME S = Surgical dressings or other medical supplies (eff 04/95) T = Psychological therapy (term. 12/31/97) outpatient mental health limitation (eff. 1/1/98) U = Occupational therapy V = Pneumococcal/flu vaccine (eff 01/96), Pneumococcal/flu/hepatitis B vaccine (eff 04/95-12/95), Pneumococcal only before 04/95 W = Physical therapy Y = Second opinion on elective surgery (obsoleted 1/97) Z = Third opinion on elective surgery (obsoleted 1/97) CTGRY_EQTBL_BENE_IDENT_TB Category Equatable Beneficiary Identification Code (BIC) Table NCH BIC SSA Categories ------- -------------- A = A;J1;J2;J3;J4;M;M1;T;TA B = B;B2;B6;D;D4;D6;E;E1;K1;K2;K3;K4;W;W6; TB(F);TD(F);TE(F);TW(F) B1 = B1;BR;BY;D1;D5;DC;E4;E5;W1;WR;TB(M) TD(M);TE(M);TW(M) B3 = B3;B5;B9;D2;D7;D9;E2;E3;K5;K6;K7;K8;W2 W7;TG(F);TL(F);TR(F);TX(F) B4 = B4;BT;BW;D3;DM;DP;E6;E9;W3;WT;TG(M) TL(M);TR(M);TX(M) B8 = B8;B7;BN;D8;DA;DV;E7;EB;K9;KA;KB;KC;W4 W8;TH(F);TM(F);TS(F);TY(F) BA = BA;BK;BP;DD;DL;DW;E8;EC;KD;KE;KF;KG;W9 WC;TJ(F);TN(F);TT(F);TZ(F) BD = BD;BL;BQ;DG;DN;DY;EA;ED;KH;KJ;KL;KM;WF WJ;TK(F);TP(F);TU(F);TV(F) BG = BG;DH;DQ;DS;EF;EJ;W5;TH(M);TM(M);TS(M) TY(M) BH = BH;DJ;DR;DX;EG;EK;WB;TJ(M);TN(M);TT(M) TZ(M) BJ = BJ;DK;DT;DZ;EH;EM;WG;TK(M);TP(M);TU(M) TV(M) C1 = C1;TC C2 = C2;T2 C3 = C3;T3 C4 = C4;T4 C5 = C5;T5 C6 = C6;T6 C7 = C7;T7 C8 = C8;T8 C9 = C9;T9 F1 = F1;TF F2 = F2;TQ F3-F8 = Equatable only to itself (e.g., F3 IS equatable to F3) CA-CZ = Equatable only to itself. (e.g., CA is only equatable to CA) --------------------------------------- RRB Categories 10 = 10 11 = 11 13 = 13;17 14 = 14;16 15 = 15 43 = 43 45 = 45 46 = 46 80 = 80 83 = 83 84 = 84;86 85 = 85 DMERC_CLM_NMO_CBA_IND_TB Claim National Mail Order (NMO) Competitive Bidding Area (CBA) Indicator Code Table 20001 = Beneficiary does not reside in a Competitive Bidding Area (CBA) and at least one line on the claim is subject to the National Mail Order (NMO) program. DMERC_LINE_CBA_TB Line Competitive Bidding Area (CBA) Code Table 16740 = Charlotte-Gastonia-Concor, NC-SC -- Non Mail-Order 16741 = Charlotte-Gastonia-Concor, NC-SC -- Mail-Order 17140 = Cincinnati-Middletown, OH-KY-IN -- Non Mail-Order 17141 = Cincinnati-Middletown, OH-KY-IN -- Mail-Order 17460 = Cleveland-Elyria-Mentor, OH -- Non Mail-Order 17461 = Cleveland-Elyria-Mentor, OH -- Mail-Order 19100 = Dallas-Fort Worth-Arlington, TX -- Non Mail-Order 19101 = Dallas-Fort Worth-Arlington, TX -- Mail-Order 28140 = Kansas City, MS-KS -- Non Mail-Order 28141 = Kansas City, MS-KS -- Mail-Order 33100 = Miami-Fort Lauderdale-Pompano Beach, FL - Non Mail-Order 33101 = Miami-Fort Lauderdale-Pompano Beach, FL - Mail-Order 36740 = Orlando-Kissimmee, FL -- Non Mail-Order 36741 = Orlando-Kissimmee, FL -- Mail-Order 38300 = Pittsburgh, PA -- Non Mail-Order 38301 = Pittsburgh, PA -- Mail-Order 40140 = Riverside-San Bernardino, CA -- Non Mail-Order 40141 = Riverside-San Bernardino, CA -- Mail-Order DMERC_LINE_DCSN_IND_TB DMERC Line Decision Indicator Table O = Original MR determination R = MR determination after reversal of original decision DMERC_LINE_FRGN_ADR_IND_TB DMERC Line Foreign Address Indicator Table EX = Expatriate Beneficiary DMERC_LINE_MTUS_IND_TB DMERC Line Miles/Time/Units Indicator Table 0 = Values reported as zero 3 = Number of services 4 = Oxygen volume units 6 = Drug dosage -- since early 1994 this value has incorrectly been placed on DMERC claims. The DMERCs were overriding the MTUS indicator with a '6' if the claim was submitted with an NDC code. NOTE: It was recently discovered that this problem has been corrected -- no date on when the correction became effective. DMERC_LINE_RRB_EXCLSN_IND_TB DMERC Line RRB Exclusion Indicator Table Y = Exclude RRB beneficiary services from the prior authorization program Blank = Subject RRB beneficiary services to prior authorization DMERC_LINE_SCRN_RSLT_IND_TB DMERC Line Screen Result Indicator Table A = Denied for lack of medical necessity; highest level of review was automated level I review B = Reduced (partially denied) for lack of medical necessity; highest level of review was automated level I review C = Denied as statutorily noncovered; highest level of review was automated level I review D = Reserved for future use E = Paid after automated level I review F = Denied for lack of medical necessity; highest level of review was manual level I review G = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level I review H = Denied as statutorily noncovered; highest level of review was manual level I review I = Denied for coding/unbundling reasons; highest level of review was manual level I review J = Paid after manual level I review K = Denied for lack of medical necessity; highest level of review was manual level II review L = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level II review M = Denied as statutorily noncovered; highest level of review was manual level II review N = Denied for coding/unbundling reasons; highest level of review was manual level II review O = Paid after manual level II review P = Denied for lack of medical necessity; highest level of review was manual level III review Q = Reduced (partially denied) for lack of medical necessity; highest level of review was manual level III review R = Denied as statutorily noncovered; highest level of review was manual level III review S = Denied for coding/unbundling reasons; highest level of review was manual level III review T = Paid after manual level III review DMERC_LINE_SCRN_SUSPNSN_IND_TB DMERC Line Screen Suspension Indicator Table MUXX = Mandated unbundling screens UXXX = Local unbundling screens CXXX = Statutorily noncovered screens M1XX = Mandate CAT I screens 1XXX = Local CAT I screens M2XX = Mandate CAT II screens 2XXX = Local CAT II screens M3XX = Mandate CAT III screens 3XXX = Local CAT III screens DMERC_LINE_SUPLR_TYPE_TB DMERC Line Supplier Type Table 0 = Clinics, groups, associations, Intervention, or other entities for which the carrier's own ID number has been assigned. 1 = Physicians or suppliers billing as solo practitioners for whom SS numbers are shown in the physician ID code field. 2 = Physicians or suppliers billing as solo practitioners for the carrier's own physician ID code is shown. 3 = Suppliers (other than sole) 4 = Suppliers (other than sole proprietorship) for whom the carrier's own code has been shown. 5 = Institutional providers and independent laboratories for whom EI numbers are used in coding the ID field. 6 = Institutional providers and independent laboratories for whom the carrier's own ID number is shown. 7 = Clinics, groups, associations, or partnerships for whom EI numbers are used in coding the ID field. 8 = Other entities for whom EI numbers are used in coding the ID field. END_REC_TB End of Record Code Table EOR = End of record/segment EOC = End of claim GEO_SSA_STATE_TB State Table 01 = Alabama 02 = Alaska 03 = Arizona 04 = Arkansas 05 = California 06 = Colorado 07 = Connecticut 08 = Delaware 09 = District of Columbia 10 = Florida 11 = Georgia 12 = Hawaii 13 = Idaho 14 = Illinois 15 = Indiana 16 = Iowa 17 = Kansas 18 = Kentucky 19 = Louisiana 20 = Maine 21 = Maryland 22 = Massachusetts 23 = Michigan 24 = Minnesota 25 = Mississippi 26 = Missouri 27 = Montana 28 = Nebraska 29 = Nevada 30 = New Hampshire 31 = New Jersey 32 = New Mexico 33 = New York 34 = North Carolina 35 = North Dakota 36 = Ohio 37 = Oklahoma 38 = Oregon 39 = Pennsylvania 40 = Puerto Rico 41 = Rhode Island 42 = South Carolina 43 = South Dakota 44 = Tennessee 45 = Texas 46 = Utah 47 = Vermont 48 = Virgin Islands 49 = Virginia 50 = Washington 51 = West Virginia 52 = Wisconsin 53 = Wyoming 54 = Africa 55 = California 56 = Canada & Islands 57 = Central America and West Indies 58 = Europe 59 = Mexico 60 = Oceania 61 = Philippines 62 = South America 63 = U.S. Possessions 64 = American Samoa 65 = Guam 66 = Commonwealth of the Northern Marianas Islands 67 = Texas 68 = Florida (eff. 10/2005) 69 = Florida (eff. 10/2005) 70 = Kansas (eff. 10/2005) 71 = Louisiana (eff. 10/2005) 72 = Ohio (eff. 10/2005) 73 = Pennsylvania (eff. 10/2005) 74 = Texas (eff. 10/2005) 75 - California 76 - Iowa 77 - Minnesota 78 - Illinois 79 - Missouri 80 = Maryland (eff. 8/2000) 96 = New Mexico 97 = Texas 98 = Guam 99 = Foreign Countries (exceptions: Canada or Mexico) A0 = California (eff. 4/2019) A1 = California (eff. 4/2019) A2 = Florida (eff. 4/2019) A3 = Louisianna (eff. 4/2019) A4 = Michigan (eff. 4/2019) A5 = Mississippi (eff. 4/2019) A6 = Ohio (eff. 4/2019) A7 = Pennsylvania (eff. 4/2019) A8 = Tennessee (eff. 4/2019) A9 = Texas (eff. 4/2019) B0 = Kentucky (eff. 4/2020) B1 = West Virginia (eff. 4/2020) B2 = California (eff. 4/2020) LINE_ADDTNL_CLM_DCMTN_IND_TB Line Additional Claim Documentation Indicator Table 0 = No additional documentation 1 = Additional documentation submitted for non-DME EMC claim 2 = CMN/prescription/other documentation submitted which justifies medical necessity 3 = Prior authorization obtained and approved 4 = Prior authorization requested but not approved 5 = CMN/prescription/other documentation submitted but did not justify medical necessity 6 = CMN/prescription/other documentation submitted and approved after prior authorization rejected 7 = Recertification CMN/prescription/other documentation LINE_CNSLDTD_BLG_TB Line Consolidated Billing Indicator Table 1 = Home Health Consolidated Billing Override Code 2 = SNF Consolidated Billing Override Code LINE_DGNS_VRSN_TB Line Diagnosis Version Code Table Valid Values: 9 = ICD-9 0 = ICD-10 LINE_DUP_CLM_CHK_IND_TB Line Duplicate Claim Check Indicator Table 1= Suspect duplicate review performed LINE_HCT_HGB_TYPE_TB Line Hematocrit/Hemoglobin Test Type Code R1 = Hemoglobin Test R2 = Hematocrit Test LINE_PLC_SRVC_TB Line Place Of Service Table 01 = Pharmacy (eff. 10/1/05) 03 = School (eff. 1/1/03 04 = Homeless Shelter (eff. 1/1/03) 09 = Prison/correctional facility setting (eff. 10/2006) 11 = Office 12 = Home 13 = Assisted Living Facility (eff. 10/1/2003) 14 = Group Home (eff. 10/1/2003) 15 = Mobile Unit (eff. 1/1/03) 18 = Place of Employment/Worksite 20 = Urgent Care Facility (eff. 1/1/03) 21 = Inpatient hospital 22 = Outpatient hospital 23 = Emergency room - hospital 24 = Ambulatory surgical center 25 = Birthing center 26 = Military treatment facility 31 = Skilled nursing facility 32 = Nursing facility 33 = Custodial care facility 34 = Hospice 35 = Adult living care facilities (ALCF) (eff. NYD - added 12/3/97) 41 = Ambulance - land 42 = Ambulance - air or water 49 = Independent Care (eff. 10/1/2003) 50 = Federally qualified health centers (eff. 10/1/93) 51 = Inpatient psychiatric facility 52 = Psychiatric facility partial hospitalization 53 = Community mental health center 54 = Intermediate care facility/mentally retarded 55 = Residential substance abuse treatment facility 56 = Psychiatric residential treatment center 57 = Non-residential substance abuse treatment facility (eff. 10/1/2003) 58 = Non-residential OPIOD treatment facility (eff. 1/2020) 60 = Mass immunizations center (eff. 9/1/97) 61 = Comprehensive inpatient rehabilitation facility 62 = Comprehensive outpatient rehabilitation facility 65 = End stage renal disease treatment facility 71 = State or local public health clinic 72 = Rural health clinic 81 = Independent laboratory 99 = Other unlisted facility LINE_PMT_80_100_TB Line Payment 80%/100% Table 0 = 80% 1 = 100% 3 = 100% Limitation of liability only 4 = 75% Reimbursement LINE_PRCSG_IND_TB Line Processing Indicator Table A = Allowed B = Benefits exhausted C = Noncovered care D = Denied (existed prior to 1991; from BMAD) E = MSP Cost Avoided - First Claim Development F = MSP Cost Avoided - Trauma Code Development G = MSP Cost Avoided - Secondary Claims Investigation H = MSP Cost Avoided - Self Reports I = Invalid data J = MSP Cost Avoided - 411.25 K = MSP Cost Avoided - Insurer Voluntary Reporting L = CLIA (eff 9/92) M = Multiple submittal--duplicate line item N = Medically unnecessary O = Other P = Physician ownership denial (eff 3/92) Q = MSP cost avoided (contractor #88888) - voluntary agreement (eff. 1/98) R = Reprocessed--adjustments based on subsequent reprocessing of claim S = Secondary payer T = MSP cost avoided - IEQ contractor (eff. 7/76) U = MSP cost avoided - HMO rate cell adjustment (eff. 7/96) V = MSP cost avoided - litigation settlement (eff. 7/96) X = MSP cost avoided - generic Y = MSP cost avoided - IRS/SSA data match project Z = Bundled test, no payment (eff. 1/1/98) 00 = MSP cost avoided - COB Contractor 12 = MSP cost avoided - BC/BS Voluntary Agreements 13 = MSP cost avoided - Office of Personnel Management 14 = MSP cost avoided - Workman's Compensation (WC) Datamatch 15 = MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) (eff. 4/2006) 16 = MSP cost avoided - Liability Insurer VDSA (eff.4/2006) 17 = MSP cost avoided - No-Fault Insurer VDSA (eff.4/2006) 18 = MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement (eff.4/2006) 19 = MSP cost avoided - Worker's Compensation Set Aside 21 = MSP cost avoided - MIR Group Health Plan (eff.1/2009) 22 = MSP cost avoided - MIR non-Group Health Plan (eff.1/2009) 25 = MSP cost avoided - Recovery Audit Contractor - California (eff.10/2005) 26 = MSP cost avoided - Recovery Audit Contractor - Florida (eff.10/2005) 39 = MSP cost avoided - Group Health Plan Recovery 41 = MSP cost avoided - Next Generation Desktop 42 = MSP cost avoided - Non Group Health Plan ORM 43 = MSP cost avoided - COBC Medicare Part C/Medicare Advantage NOTE: Effective 4/1/02, the Line Processing Indicator code was expanded to a 2-byte field. The NCH instituted a crosswalk from the 2-byte code to a 1-byte character code. Below are the character codes (found in NCH & NMUD). At some point, NMUD will carry the 2-byte code but NCH will continue to have the 1-byte character code. ! = MSP cost avoided - COB Contractor ('00' 2-byte code) @ = MSP cost avoided - BC/BS Voluntary Agreements ('12' 2-byte code) # = MSP cost avoided - Office of Personnel Management ('13' 2-byte code) $ = MSP cost avoided - Workman's Compensation (WC) Datamatch ('14' 2-byte code) * = MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) ('15' 2-byte code) (eff. 4/2006) ( = MSP cost avoided - Liability Insurer VDSA ('16' 2-byte code) (eff. 4/2006) ) = MSP cost avoided - No-Fault Insurer VDSA ('17' 2-byte code) (eff. 4/2006) + = MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement ('18' 2 -byte code) (eff. 4/2006) < = MSP cost avoided - MIR Group Health Plan ('21' 2-byte code) (eff. 1/2009) > = MSP cost avoided - MIR non-Group Health Plan ('22' 2-byte code) (eff. 1/2009) % = MSP cost avoided - Recovery Audit Contractor - - California ('25' 2-byte code) (eff. 10/2005) & = MSP cost avoided - Recovery Audit Contractor - Florida ('26' 2-byte code) (eff. 10/2005) LINE_PRIOR_AUTHRZTN_TB Line Prior Authorization Indicator Table A = Part A B = Part B D = DME H = Home Health and Hospice + 3 digit number LINE_PRVDR_PRTCPTG_IND_TB Line Provider Participating Indicator Table 1 = Participating 2 = All or some covered and allowed expenses applied to deductible Participating 3 = Assignment accepted/non-participating 4 = Assignment not accepted/non-participating 5 = Assignment accepted but all or some covered and allowed expenses applied to deductible Non-participating. 6 = Assignment not accepted and all covered and allowed expenses applied to deductible non-participating. 7 = Participating provider not accepting assignment. LINE_PWK_TB Line Paperwork Code Table P1 = one iteration is present P2 = two iterations are present P3 = three iterations are present P4 = four iterations are present P5 = five iterations are present P6 = six iterations are present P7 = seven iterations are present P8 = eight iterations are present P9 = nine iterations are present P0 = ten iterations are present LINE_SRVC_DDCTBL_IND_TB Line Service Deductible Indicator Switch Code Table 0 = SERVICE SUBJECT TO DEDUCTIBLE 1 = SERVICE NOT SUBJECT TO DEDUCTIBLE LINE_VLNTRY_SRVC_IND_TB Line Voluntary Service Indicator Table V = A voluntary procedure code Blank = A required procedure code LINE_WC_IND_TB Workers' Compensation Indicator Code Y = The diagnosis codes on the claims are related to the diagnosis codes on the MSP auxiliary file in CWF. Spaces MCO_OPTN_TB MCO Option Table *****For lock-in beneficiaries**** A = HCFA to process all provider bills B = MCO to process only in-plan C = MCO to process all Part A and Part B bills ***** For non-lock-in beneficiaries***** 1 = HCFA to process all provider bills 2 = MCO to process only in-plan Part A and Part B bills 4 = Cost Plan-Chronic Care Organizations (eff. 10/2005) NCH_CLM_BIC_MDFY_TB NCH Claim BIC Modify H Code Table H = BIC submitted by CWF = HA, HB or HC blank = No HA, HB or HC BIC present NCH_CLM_TYPE_TB NCH Claim Type Table 10 = HHA claim 20 = Non swing bed SNF claim 30 = Swing bed SNF claim 40 = Outpatient claim 50 = Hospice claim 60 = Inpatient claim 61 = Inpatient 'Full-Encounter' claim 62 = Medicare Advantage IME/GME Claims 63 = Medicare Advantage (no-pay) claims 64 = Medicare Advantage (paid as FFS) claims 71 = RIC O local carrier non-DMEPOS claim 72 = RIC O local carrier DMEPOS claim 81 = RIC M DMERC non-DMEPOS claim 82 = RIC M DMERC DMEPOS claim NOTE: In the data element NCH_CLM_TYPE_CD (derivation rules) the numbers for these claim types need to be changed - dictionary reflects 61 for all three. NCH_DEMO_TRLR_IND_TB NCH Demonstration Trailer Indicator Table D = Demo trailer present NCH_DGNS_TRLR_IND_TB NCH Diagnosis Trailer Indicator Table Y = Diagnosis code trailer present NCH_EDIT_DISP_TB NCH Edit Disposition Table 00 = No MQA errors 10 = Possible duplicate 20 = Utilization error 30 = Consistency error 40 = Entitlement error 50 = Identification error 60 = Logical duplicate 70 = Systems duplicate NCH_EDIT_TB NCH EDIT TABLE A0X1 = (C) PHYSICIAN-SUPPLIER ZIP CODE A000 = (C) REIMB > $100,000 OR UNITS > 150 A002 = (C) CLAIM IDENTIFIER (CAN) A003 = (C) BENEFICIARY IDENTIFICATION (BIC) A004 = (C) PATIENT SURNAME BLANK A005 = (C) PATIENT 1ST INITIAL NOT-ALPHABETIC A006 = (C) DATE OF BIRTH IS NOT NUMERIC A007 = (C) INVALID GENDER (0, 1, 2) A008 = (C) INVALID QUERY-CODE (WAS CORRECTED) A009 = (C) TYPE OF BILL RECEIVED IS 41A, 41B, OR 41D A010 = (C) DISPOSITION CODE VS. ACTION/ENTRY CODE A023 = (C) PORTABLE X-RAY WITHOUT MODIFIER A025 = (C) FOR OV 4, TOB MUST = 13,83,85,73 A031 = (C) HOSPITAL CLAIMS--CLAIM SHOWS SERVICES WERE PAID BY AN HMO AND CODITION CODE '04' IS NOT PRESENT. (TOB '11' & '12') A041 = (C) HHA CLAIMS--TOB 32X OR 33X WITH >4 VISITS; DATE OF SERVICE > 9/30/00 AND LUPA IND IS PRESENT. BYPASS FOR NON-PAYMENT CODE B, C, Q, T-Y. A1X1 = (C) PERCENT ALLOWED INDICATOR A1X2 = (C) DT>97273,DG1=7611,DG<>103,163,1589 A1X3 = (C) DT>96365,DIAG=V725 A1X4 = (C) INVALID DIAGNOSTIC CODES C050 = (U) HOSPICE - SPELL VALUE INVALID D102 = (C) DME DATE OF BIRTH INVALID D2X2 = (C) DME SCREEN SAVINGS INVALID D2X3 = (C) DME SCREEN RESULT INVALID D2X4 = (C) DME DECISION IND INVALID D2X5 = (C) DME WAIVER OF PROV LIAB INVALID D3X1 = (C) DME NATIONAL DRUG CODE INVALID D4X1 = (C) DME BENE RESIDNC STATE CODE INVALID D4X2 = (C) DME OUT OF DMERC SERVICE AREA D4X3 = (C) DME STATE CODE INVALID D5X1 = (C) TOS INVALID FOR DME HCPCS D5X2 = (C) DME HCPCS NOC & NOC DESCRIP MISSING D5X3 = (C) DME INVALID USE OF MS MODIFIER D5X4 = (C) TOS9 NDC REQD WHEN HCPCS OMITTED D5X5 = (C) TOS9 NDC REQD FOR Q0127-130 HCPCS D5X6 = (C) TOS9 NDC/DIAGNOSIS CODE INVALID D5X7 = (C) ANTI-EMETIC/ANTI-CANCER DRUG W/0 CANCER DIAGNOSIS D5X8 = (C) TWO ANTI-EMETIC DRUGS PRESENT ON SAME CLAIM WITH IDENTICAL DATES OF SERVICE. D6X1 = (C) DME SUPPLIER NUMBER MISSING D7X1 = (C) DME PURCHASE ALLOWABLE INVALID D919 = (C) CAPPED/PEN PUMPS,NUM OF SRVCS > 1 D921 = (C) SHOE HCPC W/O MOD RT,LT REQ U=2/4/6 D922 = (C) THERAPEUTIC SHOE CODES 'A5505-A5501' W/MODIFIER 'LT' OR 'RT' MUST HAVE UNITS = '001' XXXX = (D) SYS DUPL: HOST/BATCH/QUERY-CODE Y001 = (C) HCPCS R0075/UNITS>1/SERVICES=1 Y002 = (C) HCPCS R0075/UNITS=1/SERVICES>1 Y003 = (C) HCPCS R0075/UNITS=SERVICES Y010 = (C) TOB=13X/14X AND T.C.>$7,500 Y011 = (C) INP CLAIM/REIM > $350,000 Z001 = (C) RVNU 820-859 REQ COND CODE 71-76 Z002 = (C) CC M2 PRESENT/REIMB > $150,000 Z003 = (C) CC M2 PRESENT/UNITS > 150 Z004 = (C) CC M2 PRESENT/UNITS & REIM < MAX Z005 = (C) REIMB>99999 AND REIMB<150000 Z006 = (C) UNITS>99 AND UNITS<150 Z007 = (C) TOB VS TOTAL CHARGE Z008 = (C) TOB VS TOTAL CHARGE W/O 20/21 CONDITION CODE Z237 = (E) HOSPICE OVERLAP - DATE ZERO 0011 = (C) ACTION CODE INVALID 0012 = (C) IME/GME CLAIM -- '04' OR '69' CONDITION CODE 0013 = (C) CABG/PCOE/MPPD AND INVALID ADMIT DATE 0014 = (C) DEMO NUM INVALID 0015 = (C) ESRD PLAN VS DEMO NUM 0016 = (C) INVALID VA CLAIM 0017 = (C) DEMO=38 W/O CONTRACTOR #80881/80882 0018 = (C) DEMO=31,ACT CD<>1/5 OR ENT CD<>1/5 0019 = (C) DEMO 07/08 WITH CONDITION CODE B1 0020 = (C) CANCEL ONLY CODE INVALID 0021 = (C) DEMO COUNT > 1 0022 = (C) TOB '32X' OR '33X' W/DATES OF SERVICE >9/30/00 AND HAS CANCEL ONLY CODE OTHER THAN A,B,E,F 0023 = (C) DEMO '46' AND HCPCS INCONSISTENT 0301 = (C) INVALID HI CLAIM NUMBER 0302 = (C) BENE IDEN CDE (BIC) INVAL OR BLK 04A1 = (C) PATIENT SURNAME BLANK (PHYS/SUP) 04B1 = (C) PATIENT 1ST INITIAL NOT-ALPHABETIC 0401 = (C) BILL TYPE/PROVIDER INVALID 0402 = (C) BILL TYPE/REV CODE/PROVR RANGE 0403 = (C) TOB '41X'/PRVDR # 1990-1999) OR TOB '51X'/ PRVDR #6990-6999, TRANS CODE SHOULD BE '0' OR '3' 0406 = (C) MAMMOGRAPHY WITH NO HCPCS 76092 OR SEX NOT F 0407 = (C) RESPITE CARE BILL TYPE NOT 34X,NO REV 66 0408 = (C) REV CODE 403 /TYPE 71X/ PROV3800-974 041A = (C) TOB '11A' OR '11D' AND DEMO #'07' OR '08' NOT PRESENT 0410 = (C) IMMUNO DRUG OCCR-36,NO REV-25 OR 636 0412 = (C) BILL TYPE XX5 HAS ACCOM. REV. CODES 0413 = (C) CABG/PCOE BUT TOB = HHA,OUT,HOS 0414 = (C) VALU CD 61,MSA AMOUNT MISSING 0415 = (C) HOME HEALTH INCORRECT ALPHA RIC 0416 = (C) REVENUE CENTER '0022', TOB MUST BE '18X' OR '21X' 0417 = (C) REVENUE CENTER '0023', TOB MUST BE '32X' OR '33X' 0418 = (C) HHA--TOB '3X5' AND DATES OF SERVICE >9/30/00 0419 = (C) HHA--RIC 'W' MUST HAVE VALUE CODE '63'/ RIC 'V' MUST HAVE VALUE CODE '62' AND RIC 'U' MUST HAVE VALUE CODES '62' AND '63' PRESENT FOR DATES OF SERVICE > 9/30/00. 0420 = (C) HHA W/O REVENUE CODE '0023' 0421 = (C) START DATE MISSING 0422 = (C) COB VS. OVERRIDE CODE 05X4 = (C) UPIN REQUIRED FOR TYPE-OF-SERVICE 05X5 = (C) UPIN REQUIRED FOR DME 0501 = (C) REFFERING UPIN REQUIRED FOR CLINICAL LAB 0502 = (C) REFERRING UPIN INVALID 0601 = (C) GENDER INVALID 0701 = (C) CONTRACTOR/POS 1-2 PROVIDER NUM INVALID 0702 = (C) PROVIDER NUMBER VS. TOB 0703 = (C) MAMMOGRAPHY FOR NOT FEMALE 0704 = (C) INVALID CONT FOR CABG DEMO 0705 = (C) INVALID CONT FOR PCOE DEMO 0706 = (C) REVENUE CENTER CODE MAMMOGRAPHY AND BENEFICIARY <35 0901 = (C) INVALID DISP CODE OF 02 0902 = (C) INVALID DISP CODE OF SPACES 0903 = (C) INVALID DISP CODE 1001 = (C) PROF REVIEW/ACT CODE/BILL TYPE 13X2 = (C) MULTIPLE ITEMS FOR SAME SERVICE 1301 = (C) LINE COUNT NOT NUMERIC OR > 13 1302 = (C) RECORD LENGTH INVALID 1401 = (C) INVALID MEDICARE STATUS CODE 1501 = (C) ADMIT DATE/START DATE/ENTRY CODE INVALID 1502 = (C) ADMIT DATE/START CARE DATE > STAY FROM DATE 1503 = (C) ADMIT DATE INVALID WITH THRU DATE 1504 = (C) ADM/FROM/THRU DATE > TODAYS DATE 1505 = (C) HCPCS W SERVICE DATES > 09-30-94 1601 = (C) INVESTIGATION IND INVALID 1701 = (C) SPLIT IND INVALID 1801 = (C) PAY-DENY CODE INVALID 1802 = (C) HEADER AMT/LINE ITEMS DENIED 1803 = (C) MSP COST AVD/ALL MSP LI NOT SAME 1901 = (C) AB CROSSOVER IND INVALID 2001 = (C) HOSPICE OVERRIDE INVALID 2101 = (C) HMO-OVERRIDE/PATIENT-STAT INVALID 2102 = (C) PATIENT STATUS VS. TOB 2103 = (C) HIPPS RATE/CMG CODE VS. PATIENT STATUS 2201 = (C) FROM DATE/HCPCS YR INVALID 2202 = (C) STAY-FROM DATE > THRU-DATE 2203 = (C) THRU DATE INVALID 2204 = (C) FROM DATE BEFORE EFFECTIVE DATE 2205 = (C) DATE YEARS DIFFERENT ON OUTPAT 2207 = (C) MAMMOGRAPHY BEFORE 1991 2208 = (C) TOB '21X', REV CODE 0022 FROM DATE < 06-03-98 2209 = (C) HHA WITH OVERLAPPING DATES JUNE/JULY, SEPT/OCT 2210 = (C) TOB 41X, SERVICE DATES 6/30/00, EXCEP/NONEXCEP IND = 1,2 2212 = (C) TOB 51X WITH SERVICE DATES >6/30/00 2213 = (C) TOB 32X OR 33X, SERVICE >9/30/00 DAYS CAN NOT = 60 2215 = (C) DEMO 37 WITH VALUE CODES 'A2', 'B2', 'C2' 2216 = (C) DEMO 37 OR CONDITION CODE 78 AND CHARGES SUB TO DED > 0 2301 = (C) DOCUMENT CNTL OR UTIL DYS INVALID 2302 = (C) COVERED DAYS INVALID OR INCONSIST 2303 = (C) COST REPORT DAYS > ACCOMIDATION 2304 = (C) UTIL DAYS = ZERO ON PATIENT BILL 2305 = (C) LATE CHARGE BILL WITH DATA FIELD PRESENT 2306 = (C) UTIL DYS/NOPAY/REIMB INCONSISTENT 2307 = (C) COND=40,UTL DYS >0/VAL CDE A1,08,09 2308 = (C) NOPAY = R WHEN UTIL DAYS = ZERO 2401 = (C) NON-UTIL DAYS INVALID 2501 = (C) CLAIM RCV DT OR COINSURANCE INVAL 2502 = (C) COIN+LR>UTIL DAYS/RCPT DTE>CUR DTE 2503 = (C) COIN/TR TYP/UTIL DYS/RCPT DTE>PD/DEN 2504 = (C) COINSURANCE AMOUNT EXCESSIVE 2505 = (C) COINSURANCE RATE > ALLOWED AMOUNT 2506 = (C) COINSURANCE DAYS/AMOUNT INCONSIST 2507 = (C) COIN+LR DAYS > TOTAL DAYS FOR YR 2508 = (C) COINSURANCE DAYS INVALID FOR TRAN 2601 = (C) CLAIM PAID DT INVALID OR LIFE RES 2602 = (C) LR-DAYS, NO VAL 08,10/PD/DEN>CUR+27 2603 = (C) LIFE RESERVE > RATE FOR CAL YEAR 2604 = (C) PPS BILL, NO DAY OUTLIER 2605 = (C) LIFE RESERVE RATE > DAILY RATE AVR. 28XA = (C) UTIL DAYS > FROM TO BENEF EXH 28XB = (C) BENEFITS EXH DATE > FROM DATE 28XC = (C) BENEFITS EXH DATE/INVALID TRANS TYPE 28XD = (C) OCCUR 23 WITH SPAN 70 ON INPAT HOSP 28XE = (C) MULTI BENE EXH DATE (OCCR A3,B3,C3) 28XF = (C) ACE DATE ON SNF (NOPAY =B, C, N, W) 28XG = (C) SPAN CD 70+4+6+9 NOT = NONUTIL DAYS 28XM = (C) OCC CD 42 DATE NOT = SRVCE THRU DTE 28XN = (C) INVALID OCC CODE 28XO = (C) AN 'N' NO-PAY CODE IS PRESENT AND OCCURRENCE CODE '23' OR '42' IS NOT PRESENT AND THE DATE ASSOCIATED WITH CODE IS MISSING OR NOT EQUAL TO THRU DATE. 28XP = (C) THE OCCURRENCE CODE 23 DATE DOES NOT EQUAL THE THRU DATE 28X0 = (C) BENE EXH DATE OUTSIDE SERVICE DATES 28X1 = (C) OCCUR DATE INVALID 28X2 = (C) OCCUR = 20 AND TRANS = 4 28X3 = (C) OCCUR 20 DATE < ADMIT DATE 28X4 = (C) OCCUR 20 DATE > ADMIT + 12 28X5 = (C) OCCUR 20 AND ADMIT NOT = FROM 28X6 = (C) OCCUR 20 DATE < BENE EXH DATE 28X7 = (C) OCCUR 20 DATE+UTIL-COIN>COVERAGE 28X8 = (C) OCCUR 22 DATE < FROM OR > THRU 28X9 = (C) UTIL > FROM - THRU LESS NCOV 33X1 = (C) QUAL STAY DATES INVALID (SPAN=70) 33X2 = (C) QS FROM DATE NOT < THRU (SPAN=70) 33X3 = (C) QS DAYS/ADMISSION ARE INVALID 33X4 = (C) QS THRU DATE > ADMIT DATE (SPAN=70) 33X5 = (C) SPAN 70 INVALID FOR DATE OF SERVICE 33X6 = (C) TOB=18/21/28/51,COND=WO,HMO<>90091 33X7 = (C) TOB<>18/21/28/51,COND=WO 33X8 = (C) TOB=18/21/28/51,CO=WO,ADM DT<97001 33X9 = (C) TOB=32X SPAN 70 OR OCCR BO PRESENT 33#A = (C) MULTIPLE PET SCANS 33#B = (C) MULITIPLE PET SCANS W/O MODIFIER 26 OR TC 3401 = (C) DEMO ID = 04 AND RIC NOT = 1 OR 2 34X2 = (C) DEMO ID = 04 AND COND WO NOT SHOWN 34#3 = (C) CONDITION CODE = W0 AND DEMO NOT = 04 35X1 = (C) 60, 61, 66 & NON-PPS / 65 & PPS 35X2 = (C) COND = 60 OR 61 AND NO VALU 17 35X3 = (C) PRO APPROVAL COND C3,C7 REQ SPAN M0 35#3 = (C) (SECOND CONDITION) CONDITION CODE = C3 REQUIRES SPAN CODE 76 OR 77 35#4 = (C) CONDITION CODE = 69 AND TOB NOT 11X 36X1 = (C) SURG DATE < STAY FROM/ > STAY THRU 36#1 = (C) SURGICAL DATE = ZEROES OR < FROM OR > THRU DATES 3701 = (C) ASSIGN CODE INVALID 3705 = (C) 1ST CHAR OF IDE# IS NOT ALPHA 3706 = (C) INVALID IDE NUMBER-NOT IN FILE 3710 = (C) NUM OF IDE# > REV 0624 3715 = (C) NUM OF IDE# < REV 0624 3720 = (C) IDE AND LINE ITEM NUMBER > 2 3801 = (C) AMT BENE PD INVALID 3XA/ = (C) COLORECTAL/PROSTATE SCREENING BILLED MULTIPLE TIMES 4001 = (C) BLOOD PINTS FURNISHED INVALID 4002 = (C) BLOOD FURNISHED/REPLACED INVALID 4003 = (C) BLOOD FURNISHED/VERIFIED/DEDUCT 4201 = (C) BLOOD PINTS UNREPLACED INVALID 4202 = (C) BLOOD PINTS UNREPLACED/BLOOD DED 4203 = (C) INVALID CPO PROVIDER NUMBER 4301 = (C) BLOOD DEDUCTABLE INVALID 4302 = (C) BLOOD DEDUCT/FURNISHED PINTS 4303 = (C) BLOOD DEDUCT > UNREPLACED BLOOD 4304 = (C) BLOOD DEDUCT > 3 - REPLACED 4501 = (C) PRIMARY DIAGNOSIS INVALID 4502 = (C) SERVICE DATES > CURRENT DATE 46#A = (C) MSP VET AND VET AT MEDICARE 46#B = (C) MULTIPLE COIN VALU CODES (A2,B2,C2) 46#C = (C) COIN VALUE (A2,B2,C2) ON INP/SNF 46#G = (C) VALU CODE 20 INVALID 46#L = (C) BLOOD FURNISHED < BLOOD REPLACED 46#N = (C) VALUE CODE 37,38,39 INVALID 46#O = (C) VALUE CDE 37,38,39 AMOUNT NOT > 00 46#P = (C) BLD UNREP VS REV CDS AND/OR UNITS 46#Q = (C) VALUE CDE 37=39 AND 38 IS PRESENT 46#R = (C) BLD FIELDS VS REV CDE 380,381,382 46#S = (C) VALU CODE 39, AND 37 IS NOT PRESENT 46#T = (C) CABG/PCOE/MPPD,VC<>Y1,Y2,Y3,Y4,VA NOT>0 46#U = (C) MSP VALUES ON CABG/PCOE/MPPD (INP) TOB '32X'/'33X' MUST HAVE VALUE 62/64 OR 63/65 (HHA) 46#V = (C) TOB '32X'/'33X' VISITS IN 62/63 NOT = REVENUE CODE 42X-44X, 55X-57X 46#W = (C) CONDITION CODE =30/78 AND WITH VALUE CODE = A1, B1, C1 46#1 = (C) VALUE AMOUNT INVALID 46#2 = (C) VALU 06 AND BLD-DED-PTS IS ZERO 46#3 = (C) VALU 06 AND TTL-CHGS=NC-CHGS(001) 46#4 = (C) VALU (A1,B1,C1): AMT > DEDUCT 46#5 = (C) DEDUCT VALUE (A1,B1,C1) ON SNF BILL 46#6 = (C) VALU 17 AND NO COND CODE 60 OR 61 46#7 = (C) OUTLIER(VAL 17) > REIMB + VAL6-16 46#8 = (C) MULTI CASH DED VALU CODES (A1,B1,C1) 46X9 = (C) DEMO ID=03,REQUIRED HCPCS NOT SHOWN 4600 = (C) CAPITAL TOTAL NOT = CAP VALUES 4601 = (C) CABG/PCOE, MSP CODE PRESENT 4603 = (C) DEMO ID = 03 AND RIC NOT=6,7 4604 = (C) DEMO = 03 WITH DATES OF SERVICE > 09/31/01 4901 = (C) PCOE/CABG,DEN CD NOT D 4902 = (C) PCOE/CABG BUT DME 50#1 = (C) RVCD=54,TOB<>13,23,32,33,34,83,85 50#2 = (C) REV CD=054X,MOD NOT = QM,QN 5051 = (E) EDB: NOMATCH ON 3 CHARACTERISTICS 5052 = (E) EDB: NOMATCH ON MASTER-ID RECORD 5053 = (E) EDB: NOMATCH ON CLAIM-NUMBER 51#A = (C) HCPCS EYEWARE & REV CODE NOT 274 51#C = (C) HCPCS REQUIRES DIAG CODE OF CANCER 51#D = (C) HCPCS REQUIRES UNITS > ZERO 51#E = (C) HCPCS REQUIRES REVENUE CODE 636/294 51#F = (C) INV BILL TYP/ANTI-CAN DRUG HCPCS 51#G = (C) HCPCS REQUIRES DIAG OF HEMOPHILL1A 51#H = (C) TOB 21X/P82=2/3/4;REV CD<9001,>9044 51#I = (C) TOB 21X/P82<>2/3/4:REV CD>8999<9045 51#J = (C) TOB 21X/REV CD: SVC-FROM DT INVALID 51#K = (C) TOB 21X/P82=2/3/4,REV CD = NNX 51#L = (C) REV 0762/UNT>48,TOB NOT=12,13,85,83 51#M = (C) 21X,RC>9041/<9045,RC<>4/234 51#N = (C) 21X,RC>9032/<9042,RC<>4/234 51#O = (C) TWO ANTI-EMETIC/ANTI-CANCER DRUGS ON SAME CLAIM 51#P = (C) HHA/OUTPATIENT RC DATE OF SRVC MISSING 51#Q = (C) NO RC 0636 OR DTE INVALID 51#R = (C) DEMO ID=01,RIC NOT=2 51#S = (C) DEMO ID=01,RUGS<>2,3,4 OR BILL<>21 51#V = (C) TOB 72X W HCPCS 'J1955' MISSING REVENUE CENTER 636 51#W = (C) TOB 12X, 13X, 22X, 23X, 34X, 74X, 75X, 83X, HCPCS '97504', '97116', PRESENT ON SAME DAY 51#X = (C) TOB '32X-34X' REQUIRE HCPCS FOR REVENUE CODE '29X', '60X', '636' 51X0 = (C) REV CENTER CODE INVALID 51X1 = (C) REV CODE CHECK 51X2 = (C) REV CODE INCOMPATIBLE BILL TYPE 51X3 = (C) UNITS MUST BE > 0 51X4 = (C) INP:CHGS/YR-RATE,ETC; OUTP:PSYCH>YR 51X5 = (C) REVENUE NON-COVERED > TOTAL CHRGE 51X6 = (C) REV TOTAL CHARGES EQUAL ZERO 51X7 = (C) REV CDE 403 WTH NO BILL 14 23 71 85 51X8 = (C) MAMMOGRAPHY SUBMISSION INVALID 51X9 = (C) HCPCS/REV CODE/BILL TYPE 5100 = (U) TRANSITION SPELL / SNF 5160 = (U) LATE CHG HSP BILL STAY DAYS > 0 5166 = (U) PROVIDER NE TO 1ST WORK PRVDR 5167 = (U) PROVIDER 1 NE 2: FROM DT < START DT 5168 = (E) CLAIM IN HOSPICE WITH 2ND START DATE PRESENT 5169 = (U) PROVIDER NE TO WORK PROVIDER 5170 = (E) OCCURRENCE CODE = 42 AND < DOLBA 5177 = (U) PROVIDER NE TO WORK PROVIDER 5178 = (U) HOSPICE BILL THRU < DOLBA 5181 = (U) HOSP BILL OCCR 27 DISCREPANCY 5200 = (E) ENTITLEMENT EFFECTIVE DATE 5201 = (U) HOSP DATE DIFFERENCE NE 60 OR 90 5202 = (E) ENTITLEMENT HOSPICE EFFECTIVE DATE 5202 = (U) HOSPICE TRAILER ERROR 5203 = (E) ENTITLEMENT HOSPICE PERIODS 5203 = (U) HOSPICE START DATE ERROR 5204 = (U) HOSPICE DATE DIFFERENCE NE 90 5205 = (U) HOSPICE DATE DISCREPANCY 5206 = (U) HOSPICE DATE DISCREPANCY 5207 = (U) HOSPICE THRU > TERM DATE 2ND 5208 = (U) HOSPICE PERIOD NUMBER BLANK 5209 = (U) HOSPICE DATE DISCREPANCY 5210 = (E) ENTITLEMENT FRM/TRU/END DATES 5211 = (E) ENTITLEMENT DATE DEATH/THRU 5212 = (E) ENTITLEMENT DATE DEATH/THRU 5213 = (E) ENTITLEMENT DATE DEATH MBR 5220 = (E) ENTITLEMENT FROM/EFF DATES 5225 = (E) ENT INP PPS SPAN 70 DATES 5232 = (E) ENTL HMO NO HMO OVERRIDE CDE 5233 = (E) ENTITLEMENT HMO PERIODS 5234 = (E) ENTITLEMENT HMO NUMBER NEEDED 5235 = (E) ENTITLEMENT HMO HOSP+NO CC07 5236 = (E) ENTITLEMENT HMO HOSP + CC07 5237 = (E) ENTITLEMENT HOSP OVERLAP 5238 = (U) HOSPICE CLAIM OVERLAP > 90 5239 = (U) HOSPICE CLAIM OVERLAP > 60 524Z = (E) HOSP OVERLAP NO OVD NO DEMO 5240 = (U) HOSPICE DAYS STAY+USED > 90 5241 = (U) HOSPICE DAYS STAY+USED > 60 5242 = (C) INVALID CARRIER FOR RRB 5243 = (C) HMO=90091,INVALID SERVICE DTE 5244 = (E) DEMO CABG/PCOE MISSING ENTL 5245 = (C) INVALID CARRIER FOR NON RRB 525Z = (E) HMO/HOSP 6/7 NO OVD NO DEMO 5250 = (U) HOSPICE DOEBA/DOLBA 5255 = (U) HOSPICE DAYS USED 5256 = (U) HOSPICE DAYS USED > 999 526Y = (E) HMO/HOSP DEMO 5/15 REIMB > 0 526Z = (E) HMO/HOSP DEMO 5/15 REIMB = 0 5270 = (C) CONDITION CODE = 30 AND HMO REQUIRES MODIFIER = 'QV' OR 'KZ'/DED IND 5271 = (C) RISK HMO NOT PRESENT AND MOD 'KZ'/ OR CONDITION CODE 78 PRESENT 527Y = (E) HMO/HOSP DEMO OVD=1 REIMB > 0 527Z = (E) HMO/HOSP DEMO OVD=1 REIMB = 0 5299 = (U) HOSPICE PERIOD NUMBER ERROR 52#K = (C) HCPCS VS DIAGNOSIS 52#L = (C) HCPCS VS MODIFIER 52#M = (C) HCPCS VS DATES OF SERVICE 52#N = (C) TOB '71X' OR '73X' WITH REVENUE CENTER CODE 0403 MISSING REVENUE CENTER CODE 0521 52#O = (C) REVENUE CENTER CODE 0022/0024 WITH CHARGES >0 52#P = (C) REVENUE CENTER CODE 010X-021X MINUS 18X <> 0022 52#Q = (C) REVENUE CENTER CODE 0022 AND HIPPS MISSING 52#R = (C) REVENUE CENTER CODE 0022 MISSING DATE OF SERVICE 52#T = (C) REVENUE CENTER CODE 0022 MISSING REVENUE CENTER CODE 042X-044X 5320 = (U) BILL > DOEBA AND IND-1 = 2 5350 = (U) HOSPICE DOEBA/DOLBA SECONDARY 5355 = (U) HOSPICE DAYS USED SECONDARY 5362 = (C) MAMMOGRAPHY AND BENE <35 5378 = (C) SERVICE DATE < AGE 50 5379 = (C) HCPCS 'G0160' PRESENT MORE THAN ONCE 5381 = (C) HCPCS 'G0161' PRESENT MORE THAN ONCE 5382 = (C) HCPCS 'G0102-03' AND BENE <50 538Q = (C) SERVICE DATES WITHIN ALIEN RECORD 5397 = (C) DEMO '37' AND NOT CAT 74 5398 = (C) HCPCS 'G9001-G9005 & G9009-G9011 >1 OR 2 ARE PRESENT 5399 = (U) HOSPICE PERIOD NUM MATCH 539A = (C) HCPCS 'G9008' PRESENT MORE THAN ONCE 539C = (C) HCPCS 'G9013-G9015' PRESENT MORE THAN ONCE OR 2 PRESENT 5410 = (U) INPAT DEDUCTABLE 5425 = (U) PART B DEDUCTABLE CHECK 5430 = (U) PART B DEDUCTABLE CHECK 5450 = (U) PART B COMPARE MED EXPENSE 5460 = (U) PART B COMPARE MED EXPENSE 5499 = (U) MED EXPENSE TRAILER MISSING 5500 = (U) FULL DAYS/SNF-HOSP FULL DAYS 5510 = (U) COIN DAYS/SNF COIN DAYS 5515 = (U) FULL DAYS/COIN DAYS 5516 = (U) SNF FULL DAYS/SNF COIN DAYS 5520 = (U) LIFE RESERVE DAYS 5530 = (U) UTIL DAYS/LIFE PSYCH DAYS 5540 = (U) HH VISITS NE AFT PT B TRLR 5550 = (E) SNF LESS THAN PT A EFF DATE 5600 = (D) LOGICAL DUPE, COVERED 5601 = (D) LOGICAL DUPE, QRY-CDE, RIC 123 5602 = (D) LOGICAL DUPE, PANDE C, E OR I 5603 = (D) LOGICAL DUPE, COVERED 5604 = (D) LOGICAL DUPE, DATES 5605 = (D) POSS DUPE, OUTPAT REIMB 5606 = (D) POSS DUPE, HOME HEALTH COVERED U 5623 = (U) NON-PAY CODE IS P 57X1 = (C) PROVIDER SPECIALITY CODE INVALID 57X2 = (C) PHYS THERAPY/PROVIDER SPEC INVAL 57X3 = (C) PLACE/TYPE/SPECIALTY/REIMB IND 57X4 = (C) SPECIALTY CODE VS. HCPCS INVALID 57X5 = (C) HCPCS 98940-2 MODIFIER NOT = 'AT' 5700 = (U) LINKED TO THREE SPELLS 5701 = (C) DEMO ID=02,RIC NOT = 5 5702 = (C) DEMO ID=02,INVALID PROVIDER NUM 58X1 = (C) PROVIDER TYPE INVALID 58X9 = (C) TYPE OF SERVICE INVALID 5802 = (C) REIMB > $150,000 5803 = (C) UNITS/VISITS > 150 5804 = (C) UNITS/VISITS > 99 5805 = (C) OUTPATIENT CHARGE > $150,000 5806 = (C) REVENUE CENTER CODE '042X-044X' WITHOUT MODIFIER 'GN-GP' 58#4 = (C) REVENUE CENTER CODE MISSING REQUIRED HCPCS OR MODIFIER 59XA = (C) PROST ORTH HCPCS/FROM DATE 59XB = (C) HCPCS/FROM DATE/TYPE P OR I 59XC = (C) HCPCS Q0036,37,42,43,46/FROM DATE 59XD = (C) HCPCS Q0038-41/FROM DATE/TYPE 59XE = (C) HCPCS/MAMMOGRAPHY-RISK/ DIAGNOSIS 59XG = (C) INVALID TOS FOR DME 59XH = (C) HCPCS E0620/TYPE/DATE 59XI = (C) HCPCS E0627-9/ DATE < 1991 59XJ = (C) GLOBAL HCPCS TOS MUST = 2 59XK = (C) HCPCS PEN PUMP AND TOS <>9 59XL = (C) HCPCS 00104 - TOS/POS 59X1 = (C) INVALID HCPCS/TOS COMBINATION 59X2 = (C) ASC IND/TYPE OF SERVICE INVALID 59X3 = (C) TOS INVALID TO MODIFIER 59X4 = (C) KIDNEY DONOR/TYPE/PLACE/REIMB 59X5 = (C) MAMMOGRAPHY FOR MALE 59X6 = (C) DRUG AND NON DRUG BILL LINE ITEMS 59X7 = (C) CAPPED-HCPCS/FROM DATE 59X8 = (C) FREQUENTLY MAINTAINED HCPCS 59X9 = (C) HCPCS E1220/FROM DATE/TYPE IS R 5901 = (U) ERROR CODE OF Q 5A#1 = (C) DEMO=37, UNITS >1 FOR 'G9001-05' 'G9007-11', G9013-G9015' 60X1 = (C) ASSIGN IND INVALID 6000 = (U) ADJUSTMENT BILL SPELL DATA 6020 = (U) CURRENT SPELL DOEBA < 1990 6030 = (U) ADJUSTMENT BILL SPELL DATA 6035 = (U) ADJUSTMENT BILL THRU DTE/DOLBA 61X1 = (C) PAY PROCESS IND INVALID 61X2 = (C) DENIED CLAIM/NO DENIED LINE 61X3 = (C) PAY PROCESS IND/ALLOWED CHARGES 61X4 = (C) RATE MISSING OR NON-NUMERIC 61#E = (C) PROVIDER PAYMENT INCONSISTENCIES 61#F = (C) BENEFICIARY PAYMENT INCONSISTENCIES 61#G = (C) PATIENT RESPONSIBILITY INCONSISTENCIES 61#H = (C) MEDICARE PAYMENT INCONSISTENCIES 61#I = (C) LINE DATE OF SERVICE < FROM DATE > THRU DATE 61#J = (C) DUPLICATE HCPCS CODE '55873' 61#K = (C) HCPCS 'G0117-8' >2 OR BOTH PRESENT 61#L = (C) REVENUE CENTER CODE 0024 > 2 61#M = (C) REVENUE CENTER CODE 0024 VS PROVIDER NUMBER 61#N = (C) REVENUE CENTER CODE 0024 REQUIRES VALID HIPPS RATE CMG CODE 61#R = (C) HCPCS/TOB/REVENUE CENTER CODE 61#S = (C) HCPCS 'G0247' REQUIRES 'G0245-6' TO BE COVERED 61#T = (C) HCPCS CODE '0245-0246' PRESENT MULTIPLE TIMES 61#0 = (C) REVENUE CENTER CODE VS SPAN CODE '74' 61#6 = (C) PAYMENT METHOD INVALID 61#7 = (C) ANSI CODE MISSING 61#8 = (C) BLOOD CASH DEDUCTIBLE INCONSISTENCIES 61#9 = (C) CASH DEDUCTIBLE INCONSISTENCIES 6100 = (C) REV 0001 NOT PRESENT ON CLAIM 6101 = (C) REV COMPUTED CHARGES NOT=TOTAL 6102 = (C) REV COMPUTED NON-COVERED/NON-COV 6103 = (C) REV TOTAL CHARGES < PRIMARY PAYER 6105 = (C) REVE CODE 0001 > 1 6106 = TOB 3X2 REVENUE CENTER CODE 0023 NOT = TOTAL CHARGE 6109 = (C) REIMBURSEMENT > 4 OR 6 TIMES 62XA = (C) PSYC OT PT/REIM/TYPE 62XC = (C) DEMO 37 WITH REIMBURSEMENT/DED IND <>1 62X1 = (C) DME/DATE/100% OR INVAL REIMB IND 62X6 = (C) RAD PATH/PLACE/TYPE/DATE/DED 62X8 = (C) KIDNEY DONO/TYPE/100% 62X9 = (C) PNEUM VACCINE/TYPE/100% 6201 = (C) TOTAL DEDUCT > CHARGES/NON-COV 6203 = (U) HOSPICE ADJUSTMENT PERIOD/DATE 6204 = (U) HOSPICE ADJUSTMENT THRU>DOLBA 6260 = (U) HOSPICE ADJUSTMENT STAY DAYS 6261 = (U) HOSPICE ADJUSTMENT DAYS USED 6265 = (U) HOSPICE ADJUSTMENT DAYS USED 6269 = (U) HOSPICE ADJUSTMENT PERIOD# (MAIN) 63X1 = (C) DEDUCT IND INVALID 63X2 = (C) DED/HCFA COINS IN PCOE/CABG 6365 = (U) HOSPICE ADJUSTMENT SECONDARY DAYS 6369 = (U) HOSPICE ADJUSTMENT PERIOD# (SECOND) 64X1 = (C) PROVIDER IND INVALID 6430 = (U) PART B DEDUCTABLE CHECK 65X1 = (C) PAYSCREEN IND INVALID 66?? = (D) POSS DUPE, CR/DB, DOC-ID 66XX = (D) POSS DUPE, CR/DB, DOC-ID 66X1 = (C) UNITS AMOUNT INVALID 66X2 = (C) UNITS IND > 0; AMT NOT VALID 66X3 = (C) UNITS IND = 0; AMT > 0 66X4 = (C) MT INDICATOR/AMOUNT 66X7 = (C) DEMO 37/HCPCS/UNITS 6600 = (U) ADJUSTMENT BILL FULL DAYS 6610 = (U) ADJUSTMENT BILL COIN DAYS 6620 = (U) ADJUSTMENT BILL LIFE RESERVE 6630 = (U) ADJUSTMENT BILL LIFE PSYCH DYS 67X1 = (C) UNITS INDICATOR INVALID 67X2 = (C) CHG ALLOWED > 0; UNITS IND = 0 67X3 = (C) TOS/HCPCS=ANEST, MTU IND NOT = 2 67X4 = (C) HCPCS = AMBULANCE, MTU IND NOT = 1 67X6 = (C) INVALID PROC FOR MT IND 2, ANEST 67X7 = (C) INVALID UNITS IND WITH TOS OF BLOOD 67X8 = (C) INVALID PROC FOR MT IND 4, OXYGEN 6700 = (U) ADJUSTMENT BILL FULL/SNF DAYS 6710 = (U) ADJUSTMENT BILL COIN/SNF DAYS 68XA = (C) HCPCS G0117-8 >1 OR BOTH PRESENT 68XB = (C) HCPCS CODE G0245-46 > 1 68X1 = (C) INVALID HCPCS CODE 68X2 = (C) MAMMOGRAPY/DATE/PROC NOT 76092 68X3 = (C) TYPE OF SERVICE = G /PROC CODE 68X4 = (C) HCPCS NOT VALID FOR SERVICE DATE 68X5 = (C) MODIFIER NOT VALID FOR HCPCS, ETC 68X6 = (C) TYPE SERVICE INVALID FOR HCPCS, ETC 68X7 = (C) ZX MOD REQ FOR THER SHOES/INS/MOD. 68X8 = (C) ANTI-EMETIC WITHOUT ANTI-CANCER DRUG 6812 = (C) DEMO 37 WITH PRIMARY PAYER CODE 69XA = (C) MODIFIER NOT VALID FOR HCPCS/GLOBAL 69XB = (C) HCPCS CODE 97504/97116 PRESENT ON SAME DAY 69XC = (C) HCPCS CODE VS PAY PROCESS INDICATOR 69X3 = (C) PROC CODE MOD = LL / TYPE = R 69X6 = (C) PROC CODE MOD/NOT CAPPED 69X8 = (C) SPEC CODE NURSE PRACT, MOD INVAL 69X9 = (C) NURSE PRACTITIONER, MOD INVALID 6901 = (C) KRON IND AND UTIL DYS EQUALS ZERO 6902 = (C) KRON IND AND NO-PAY CODE B OR N 6903 = (C) KRON IND AND INPATIENT DEDUCT = 0 6904 = (C) KRON IND AND TRANS CODE IS 4 6910 = (C) REV CODES ON HOME HEALTH 6911 = (C) REV CODE 274 ON OUTPAT AND HH ONLY 6912 = (C) REV CODE INVAL FOR PROSTH AND ORTHO 6913 = (C) REV CODE INVAL FOR OXYGEN 6914 = (C) REV CODE INVAL FOR DME 6915 = (C) PURCHASE OF RENT DME INVAL ON DATES 6916 = (C) PURCHASE OF RENT DME INVAL ON DATES 6917 = (C) PURCHASE OF LIFT CHAIR INVAL > 91000 6918 = (C) HCPCS INVALID ON DATE RANGES 6919 = (C) DME OXYGEN ON HH INVAL BEFORE 7/1/89 6920 = (C) HCPCS INVAL ON REV 270/BILL 32-33 6921 = (C) HCPCS ON REV CODE 272 BILL TYPE 83X 6922 = (C) HCPCS ON BILL TYPE 83X -NOT REV 274 6923 = (C) RENTAL OF DME CUSTOMIZE AND REV 291 6924 = (C) INVAL MODIFIER FOR CAPPED RENTAL 6925 = (C) HCPCS ALLOWED ON BILL TYPES 32X-34X 6929 = (U) ADJUSTMENT BILL LIFE RESERVE 6930 = (U) ADJUSTMENT BILL LIFE PSYCH DYS 7000 = (U) INVALID DOEBA/DOLBA 7002 = (U) LESS THAN 60/61 BETWEEN SPELLS 7010 = (E) TOB 85X/ELECTN PRD: COND CD 07 REQD 71X1 = (C) SUBMITTED CHARGES INVALID 71X2 = (C) MAMMOGRPY/PROC CODE MOD TC,26/CHG 71X3 = (C) HCPCS 76092 PAY INDICATOR <> A,R,S & 76085 PAY INDICATOR A,R,S 72X1 = (C) ALLOWED CHGS INVALID 72X2 = (C) ALLOWED/SUBMITTED CHARGES/TYPE 72X3 = (C) DENIED LINE/ALLOWED CHARGES 7230 = (C) FRAMES >1, LENSES >2 73X1 = (C) SS NUMBER INVALID 73X2 = (C) CARRIER ASSIGNED PROV NUM MISSING 74X1 = (C) LOCALITY CODE INVAL FOR CONTRACT 76X1 = (C) PL OF SER INVAL ON MAMMOGRAPHY BILL 77X1 = (C) PLACE OF SERVICE INVALID 77X2 = (C) PHYS THERAPY/PLACE 77X3 = (C) PHYS THERAPY/SPECIALTY/TYPE 77X4 = (C) ASC/TYPE/PLACE/REIMB IND/DED IND 77X6 = (C) TOS=F, PL OF SER NOT = 24 7701 = (C) INCORRECT MODIFIER 7777 = (D) POSS DUPE, PART B DOC-ID 78XA = (C) MAMMOGRAPHY BEFORE 1991 78XB = (C) ANTI-CANCER BEFORE 01/01/1998 78X1 = (C) FROM DATE IMPOSSIBLE 78X2 = (C) FROM DATE > CURRENT DATE OR < 07/01/1966 78X3 = (C) FROM DATE GREATER THAN THRU DATE 78X4 = (C) FROM DATE > RCVD DATE/PAY-DENY 78X5 = (C) FROM DATE > PAID DATE/TYPE/100% 78X7 = (C) LAB EDIT/TYPE/100%/FROM DATE 79X1 = (C) THRU DATE IMPOSSIBLE 79X2 = (C) THRU DATE > CURRENT DATE 79X3 = (C) THRU DATE>RECD DATE/NOT DENIED 79X4 = (C) THRU DATE>PAID DATE/NOT DENIED 8000 = (U) MAIN & 2NDARY DOEBA < 01/01/90 8028 = (E) NO ENTITLEMENT 8029 = (U) HH BEFORE PERIOD NOT PRESENT 8030 = (U) HH BILL VISITS > PT A REMAINING 8031 = (U) HH PT A REMAINING > 0 8032 = (U) HH DOLBA+59 NOT GT FROM-DATE 8050 = (U) HH QUALIFYING INDICATOR = 1 8051 = (U) HH # VISITS NE AFT PT B APPLIED 8052 = (U) HH # VISITS NE AFT TRAILER 8053 = (U) HH BENEFIT PERIOD NOT PRESENT 8054 = (U) HH DOEBA/DOLBA NOT > 0 8060 = (U) HH QUALIFYING INDICATOR NE 1 8061 = (U) HH DATE NE DOLBA IN AFT TRLR 8062 = (U) HH NE PT-A VISITS REMAINING 81X1 = (C) NUM OF SERVICES INVALID 83X1 = (C) DIAGNOSIS INVALID 8301 = (C) HCPCS/GENDER DIAGNOSIS 8302 = (C) HCPCS G0101 V-CODE/SEX CODE 8303 = (C) HCPCS/GENDER 8304 = (C) BILL TYPE INVALID FOR G0123/4 8305 = (C) HCPCS/SERVICE DATES/GENDER 84X1 = (C) PAP SMEAR/DIAGNOSIS/GENDER/PROC 84X2 = (C) INVALID DME START DATE 84X3 = (C) INVALID DME START DATE W/HCPCS 84X4 = (C) HCPCS G0101 V-CODE/SEX CODE 84X5 = (C) HCPCS CODE WITH INV DIAG CODE 84X6 = (C) HCPCS/GENDER 84X7 = (C) HCPCS/SERVICE DATES/GENDER 84X8 = (C) DUPLICATE HCPCS 86X1 = (C) CLINICAL LAB HCPCS W/O CLINICAL LAB ID 86X2 = (C) NON-WAIVER HCPCS/PAY DENIAL CODE/ MODIFIER 86X8 = (C) CLIA REQUIRES NON-WAIVER HCPCS 88XX = (D) POSS DUPE, DOC-ID,UNITS,ENT,ALWD 9000 = (U) DOEBA/DOLBA CALC 9005 = (U) FULL/COINS HOSP DAYS CALC 9010 = (U) FULL/COINS SNF DAYS CALC 9015 = (U) LIFE RESERVE DAYS CALC 9020 = (U) LIFE PSYCH DAYS CALC 9030 = (U) INPAT DEDUCTABLE CALC 9040 = (U) DATA INDICATOR 1 SET 9050 = (U) DATA INDICATOR 2 SET 91X1 = (C) PATIENT REIMB/PAY-DENY CODE 92X1 = (C) PATIENT REIMB INVALID 92X2 = (C) PROVIDER REIMB INVALID 92X3 = (C) LINE DENIED/PATIENT-PROV REIMB 92X4 = (C) MSP CODE/AMT/DATE/ALLOWED CHARGES 92X5 = (C) CHARGES/REIMB AMT NOT CONSISTANT 92X7 = (C) REIMB/PAY-DENY INCONSISTANT 9201 = (C) UPIN REF NAME OR INITIAL MISSING 9202 = (C) UPIN REF FIRST 3 CHAR INVALID 9203 = (C) UPIN REF LAST 3 CHAR NOT NUMERIC 93X1 = (C) CASH DEDUCTABLE INVALID 93X2 = (C) DEDUCT INDICATOR/CASH DEDUCTIBLE 93X3 = (C) DENIED LINE/CASH DEDUCTIBLE 93X4 = (C) FROM DATE/CASH DEDUCTIBLE 93X5 = (C) TYPE/CASH DEDUCTIBLE/ALLOWED CHGS 9300 = (C) UPIN OTHER, NOT PRESENT 9301 = (C) UPIN NME MIS/DED TOT LI>0 FR DEN CLM 9302 = (C) UPIN OPERATING, FIRST 3 NOT NUMERIC 9303 = (C) UPIN L 3 CH NT NUM/DED TOT LI>YR DED 9351 = (C) OTHER UPIN PRESENT/MISSING OTHER FIELDS 9352 = (C) OTHER UPIN INVALID 9353 = (C) OTHER UPIN INVALID 94A1 = (C) NON-COVERED FROM DATE INVALID 94A2 = (C) NON-COVERED FROM > THRU DATE 94A3 = (C) NON-COVERED THRU DATE INVALID 94A4 = (C) NON-COVERED THRU DATE > ADMIT 94A5 = (C) NON-COVERED THRU DATE/ADMIT DATE 94C1 = (C) PR-PSYCH DAYS INVALID 94C3 = (C) PR-PSYCH DAYS > PROVIDER LIMIT 94F1 = (C) REIMBURSEMENT AMOUNT INVALID 94F2 = (C) REIMBURSE AMT NOT 0 FOR HMO PAID 94G1 = (C) NO-PAY CODE INVALID 94G2 = (C) NO-PAY CODE SPACE/NON-COVERD=TOTL 94G3 = (C) NO-PAY/PROVIDER INCONSISTANT 94G4 = (C) NO PAY CODE = R & REIMB PRESENT 94X1 = (C) BLOOD LIMIT INVALID 94X2 = (C) TYPE/BLOOD DEDUCTIBLE 94X3 = (C) TYPE/DATE/LIMIT AMOUNT 94X4 = (C) BLOOD DED/TYPE/NUMBER OF SERVICES 94X5 = (C) BLOOD/MSP CODE/COMPUTED LINE MAX 9401 = (C) BLOOD DEDUCTIBLE AMT > 3 9402 = (C) BLOOD FURNISHED > DEDUCTIBLE 9403 = (C) DATE OF BIRTH MISSING ON PRO-PAY 9404 = (C) INVALID GENDER CODE ON PRO-PAY 9407 = (C) INVALID DIAGNOSIS 9408 = (C) INVALID DRG NUMBER (GLOBAL) 9409 = (C) HCFA DRG<>DRG ON BILL 940X = (C) INVALID DRG 9410 = (C) CABG/PCOE,INVALID DRG 95X1 = (C) MSP CODE G/DATE BEFORE 1/1/87 95X2 = (C) MSP AMOUNT APPLIED INVALID 95X3 = (C) MSP AMOUNT APPLIED > SUB CHARGES 95X4 = (C) MSP PRIMARY PAY/AMOUNT/CODE/DATE 95X5 = (C) MSP CODE = G/DATE BEFORE 1987 95X6 = (C) MSP CODE = X AND NOT AVOIDED 95X7 = (C) MSP CODE VALID, CABG/PCOE 96X1 = (C) OTHER AMOUNTS INVALID 96X2 = (C) OTHER AMOUNTS > PAT-PROV REIMB 97X1 = (C) OTHER AMOUNTS INDICATOR INVALID 97X2 = (C) GRUDMAN SW/GRUDMAN AMT NOT > 0 98X1 = (C) COINSURANCE INVALID 98X3 = (C) MSP CODE/TYPE/COIN AMT/ALLOW/CSH 98X4 = (C) DATE/MSP/TYPE/CASH DED/ALLOW/COI 98X5 = (C) DATE/ALLOW/CASH DED/REIMB/MSP/TYP 9801 = (C) REV CENTER CODE 0910 WITH SERVICE DATE > 10/15/2004 99XX = (D) POSS DUPE, PART B DOC-ID 9901 = (C) REV CODE INVALID OR TRAILER CNT=0 9902 = (C) ACCOMMODATION DAYS/FROM/THRU DATE 9903 = (C) NO CLINIC VISITS FOR RHC 9904 = (C) INCOMPATIBLE DATES/CLAIM TYPE 991X = (C) NO DATE OF SERVICE 9910 = (C) BLOOD DEDUCTIBLE NON NUMERIC 9911 = (C) BLOOD DEDUCTIBLE PRESENT WITHOUT BLOOD FURNISHED 9920 = (C) CASH DEDUCTIBLE INVALID 9930 = (C) COINSURANCE INVALID 9931 = (C) OUTPAT COINSURANCE VALUES 9933 = (C) RATE EXCEDES MAMMOGRAPHY LIMIT 9934 = (C) HCPCS 76092 NON COVERED/76085 COVERED 9940 = (C) PROVIDER PAYMENT INVALID 9941 = (C) REIMBURSEMENT AMOUNT/COND/NON-PAYMENT/ PRIMARY PAYER 9942 = (C) PATIENT DISTRIBUTION INVALID 9944 = (C) STAY FROM>97273,DIAG<>V103,163,7612 9945 = (C) HCPCS INVALID FOR SERVICE DATES 9946 = (C) TOB INVALID FOR HCPCS 9947 = (C) INVALID DATE FOR HCPCS 9948 = (C) STAY FROM>96365,DIAG=V725 9960 = (C) MED CHOICE BUT HMO DATA MISSING 9965 = (C) HMO PRESENT BUT MED CHOICE MISSING 9968 = (C) MED CHOICE NOT= HMO PLAN NUMBER 9999 = (U) MAIN SPELL TRAILER NUMBER DOES NOT MATCH SPELL NCH_EDIT_TRLR_IND_TB NCH Edit Trailer Indicator Table E = Edit code trailer present NCH_LINE_TRLR_IND_TB NCH Line Item Trailer Indicator Table L = Line Item trailer present Blank = No trailer present NCH_MCO_TRLR_IND_TB NCH Managed Care Organization (MCO) Trailer Indicator Table M = MCO trailer present NCH_MQA_RIC_TB NCH MQA Record Identification Code Table 1 = Inpatient 2 = SNF 3 = Hospice 4 = Outpatient 5 = Home Health Agency 6 = Physician/Supplier 7 = Durable Medical Equipment NCH_NEAR_LINE_REC_VRSN_TB NCH Near Line Record Version Table A = Record format as of January 1991 B = Record format as of April 1991 C = Record format as of May 1991 D = Record format as of January 1992 E = Record format as of March 1992 F = Record format as of May 1992 G = Record format as of October 1993 H = Record format as of September 1998 I = Record format as of July 2000 J = Record format as of January 2011 K = Record format as of April 2013 L = Record format as of January 2021 NCH_NEAR_LINE_RIC_TB NCH Near-Line Record Identification Code Table O = Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services) V = Part A institutional claim record (inpatient (IP), skilled nursing facility (SNF), christian science (CS), home health agency (HHA), or hospice) W = Part B institutional claim record (outpatient (OP), HHA) U = Both Part A and B institutional home health agency (HHA) claim records -- due to HHPPS and HHA A/B split. (effective 10/00) M = Part B DMEPOS claim record (processed by DME Regional Carrier) (effective 10/93) NCH_PATCH_TB NCH Patch Table 01 = RRB Category Equatable BIC - changed (all claim types) -- applied during the Nearline 'G' conversion to claims with NCH weekly process date before 3/91. Prior to Version 'H', patch indicator stored in redefined Claim Edit Group, 3rd occurrence, position 2. 02 = Claim Transaction Code made consistent with NCH payment/edit RIC code (OP and HHA) -- effective 3/94, CWFMQA began patch. During 'H' conversion, patch applied to claims with NCH weekly process date prior to 3/94. Prior to version 'H', patch indicator stored in redefined Claim Edit Group, 4th occurrence, position 1. 03 = Garbage/nonnumeric Claim Total Charge Amount set to zeroes (Instnl) -- during the Version 'G' conversion, error occurred in the deriva- tion of this field where the claim was missing revenue center code = '0001'. In 1994, patch was applied to the OP and HHA SAFs only. (This SAF patch indicator was stored in the redefined Claim Edit Group, 4th occurrence, position 2). During the 'H' ocnversion, patch applied to Nearline claims where garbage or nonnumeric values. 04 = Incorrect bene residence SSA standard county code '999' changed (all claim types) -- applied during the Nearline 'G' conversion and ongoing through 4/21/94, calling EQSTZIP routine to claims with NCH weekly process date prior to 4/22/94. Prior to Version 'H' patch indicator stored in redefined Claim Edit Group, 3rd occurrence, position 4. 05 = Wrong century bene birth date corrected (all claim types) -- applied during Nearline 'H' conversion to all history where century greater than 1700 and less than 1850; if century less than 1700, zeroes moved. 06 = Inconsistent CWF bene medicare status code made consistent with age (all claim types) -- applied during Nearline 'H' conversion to all history and patched ongoing. Bene age is calculated to determine the correct value; if greater than 64, 1st position MSC ='1'; if less than 65, 1st position MSC = '2'. 07 = Missing CWF bene medicare status code derived (all claim types) -- applied during Nearline 'H' conversion to all history and patched ongoing, except claims with unknown DOB and/ or Claim From Date='0' (left blank). Bene age is calculated to determine missing value; if greater than 64, MSC='10'; if less than 65, MSC = '20'. 08 = Invalid NCH primary payer code set to blanks (Instnl) -- applied during Version 'H' con- version to claims with NCH weekly process date 10/1/93-10/30/95, where MSP values = invalid '0', '1', '2', '3' or '4' (caused by erroneous logic in HCFA program code, which was corrected on 11/1/95). 09 = Zero CWF claim accretion date replaced with NCH weekly process date (all claim types) -- applied during Version 'H' conversion to Instnl and DMERC claims; applied during Version 'G' conversion to non-institutional (non-DMERC) claims. Prior to Version 'H', patch indicator stored in redefined claim edit group, 3rd occurrence, position 1. 10 = Multiple Revenue Center 0001 (Outpatient, HHA and Hospice) -- patch applied to 1998 & 1999 Nearline and SAFs to delete any revenue codes that followed the first '0001' revenue center code. The edit was applied across all institutional claim types, including Inpatient/ SNF (the problem was only found with OP/HHA/ Hospice claims). The problem was corrected 6/25/99. 11 = Truncated claim total charge amount in the fixed portion replaced with the total charge amount in the revenue center 0001 amount field -- service years 1998 & 1999 patched during quarterly merge. The 1998 & 1999 SAFs were corrected when finalized in 7/99. The patch was done for records with NCH Daily Process Date 1/4/99 - 5/14/99. 12 = Missing claim-level HHA Total Visit Count -- service years 1998, 1999 & 2000 patch applied during Version 'I' conversion of both the Nearline and SAFs. Problem occurs in those claims recovered during the missing claims effort. 13 = Inconsistent Claim MCO Paid Switch made consistent with criteria used to identify an inpatient encounter claim -- if MCO paid switch equal to blank or '0' and ALL conditions are met to indicate an inpatient encounter claim (bene enrolled in a risk MCO during the service period), change the switch to a '1'. The patch was applied during the Version 'I' conversion, for claims back to 7/1/97 service thru date. 14 = SNF claims incorrectly identified as Inpatient Encounter claims -- SNF claims matching the Inpatient encounter data criteria were incorrectly identified as Inpatient encounter claims (claim type code = '61' instead of '20' or '30'). NOTE: if the SNF claims were identified the MCO paid switch was set to '1'. The patch was applied to correctly identify these claims as a '20' or '30'. The MCO paid switch will be set to '0' as there is no way to recover the original value. The problem occurred in claims with an NCH Weekly Process Date ranging from 7/7/2000 - 1/26/2001. The patch applied date is 03/30/2001. 15 = HHA Part A claims with overlaid revenue center lines - During the Version 'I' conversion, NCH made each segment of a claim contains a maximum of 45 revenue lines. During the month of June 2000 our CWFMQA had to be ready to except the new expanded format, but the NCH was not ready. CWFMQA converted these 'I' claims back to Version 'H', a typo in the code caused the additional revenue lines to overlay some of the revenue lines on the base/initial record/segment. The problem occurred in claims with NCH Weekly Process dates from 6/16/00, 6/23/00, 6/30/00 and 7/7/00 (both Version 'H' & 'I' files). In the Version 'I' files, the annual service year 2000 files, service year 1999 and 1998 trickles were patched. The 18-month service year 1999 was also patched (the service year 2000 SAF was created after the fix was applied). The patch applied date is 06/29/2001. NCH_PATCH_TRLR_IND_TB NCH Patch Trailer Indicator Table P = Patch code trailer present NCH_STATE_SGMT_TB NCH State Segment Table NCH State Segment State Codes ----------------- ----------------------- B = 01;02;03;04;06;07;08;09; 12;13;16;17;19;20;21;25; 27;28;29;30;32;35;37;38; 40;41;42;43;44;46;47;48; 50;51;53-99 C = 11;14;15;18;24;26;49;52 D = 11;14;15;18;24;26;31;34; 45;49;52 E = 22;23;31;34;36;45 F = 10;22;23;31;34;36;45 G = 10;22;23;36;39 H = 05;10;22;23;39 I = 05;10;39 J = 05;10;33;39 K = 05;33;39 L = 05;33;39 M = 05;33 N = 05;33 O = 33 P = 33 Q = 33 R = 33 RP_IND_TB Claim Representative Payee (RP) Indicator Code Table R = bypass representative payee Space RSDL_PMT_IND_TB Claim Residual Payment Indicator Code Table X = Residual Payment Space YES_NO_TB Yes/No Table Y = Yes N = No QUERY: RIFQQ11, RIFQQ21 ON DB2T *******END OF TOC APPENDIX FOR RECORD: DMERC_CLM_REC******** 1 LIMITATIONS APPENDIX FOR RECORD: DMERC_CLM_REC, STATUS: PROD, VERSION: 21006 PRINTED: 01/29/2021, USER: F43D, DATA SOURCE: CA REPOSITORY ON DB2T CHOICES_DEMO_LIM FULL NAME: Choices Demonstration Limitation DESCRIPTION : A programming error created an 'INVALID' indication in the demo text field for CHOICES claims. BACKGROUND : In 6/00, the CWFMQA front-end editing revealed that some CHOICES demo claims were coming in with a valid 'H' number in the fixed portion of the claims, but in the first occurrence MCO trailer a numeric packed field (value hex '0100000C') was moved to the MCO Contract Number/Option Code fields. This created an invalid period check of number/code to MCO effective date, resulting in an INVALID indication in the demo info text field. CORRECTIVE ACTION : The problem was forwarded to the CWF BSOG staff for further investigation. SOURCE: CONTACT : OIS/EDG/DMUDD CLM_ACNT_NUM_LIM FULL NAME: Beneficiary Claim Account Number Limitation DESCRIPTION : RRB-issued numbers contain an overpunch in the first position that may appear as a plus zero or A-G. RRB-formatted numbers may cause matching problems on non-IBM machines. SOURCE: NCH_CLM_TYPE_CD_LIM FULL NAME: NCH Claim Type Code Limitation DESCRIPTION : As of the implementation of Version 'J', the NCH claim type codes '62' and '64' were not correctly being set. BACKGROUND : With the implementation of Version'J', we added three new claim type codes ('62', '63' and '64') to identify Medicare Advantage claims. It appears that the conversion code we used to convert all of our history files (claims prior to start of Version 'J') set the 62 and 64 correctly but that same code was not used in our normal monthly claims processing (claims received January 1, 2011 and after). The error was with the MCO-PD-SW logic used to derive the claim type code. CORRECTIVE ACTION : This anamoly was handled in two phases: Phase 1 -- a fix was put into the NCH code to use the correct MCO-PD-SW logic. The fix was imple- mented prior to our October 2012 NCH monthly load. This fix corrected the claims received October 1st and forward. Phase 2 -- History files (January 1, 2011 thru September 28, 2012) were corrected during our NCH Version 'K' conversion, which was implemented April 2013. SOURCE: ADMINISTRATIVE DATA: START DATE : 01/01/2011 END DATE : 10/01/2012 NCH_DAILY_PROC_DT_LIM FULL NAME: NCH Daily Process Date Limitation DESCRIPTION : The NCH Daily Process Date was mistakenly changed on all Version 'J' claims during the history conversion process. BACKGROUND : It was discovered during the process of modifying the conversion code used during Version 'J' processing that the NCH Daily Process Date was mistakenly changed in the Version 'J' conversion code. When preparing the specs for the Version 'J' conversion code, we were told to change the NCH Daily Process Date to reflect the date the history files were converted. This change impacts the linkage of Part A claims that have multiple segments (claims with more than 45 revenue center lines) on the Version 'J' claim files. The NCH Daily Process Date is used in conjuction with the NCH Segment Link Number to keep records/segments belonging to a specific claim together. There is the possibility that two different claims could now have the same NCH Daily Process Date and NCH Segment Link Number. This could cause users of the data to match claim records/segments together that should not be paired. We believe the chances of this occurring to be minimal. CORRECTIVE ACTION : Because the Version 'I' files were converted and the date changed, we have no way of going back and retrieving the original NCH Daily Process Date so no fix/patch will be applied. SOURCE: CONTACT : OIS/EDG/DDOM PMT_AMT_EXCEDG_CHRG_AMT_LIM FULL NAME: Claim Payment Amount Exceeding Total Charge Amount Limitation DESCRIPTION : Approximately 75 Inpatient claims had a reimbursement amount exceed $500,000 which was at least 25 times the total charge amount. There were also claims where the reimbursement was less than $500,000 but greater than the total charges. Prior to 4/6/93, on inpatient, outpatient, and physician/supplier claims containing a CLM_DISP_CD of '02', the amount shown as the Medicare reimbursement does not take into consideration any CWF automatic adjustments (involving erroneous deductibles in most cases). In as many as 30% of the claims (30% IP, 15% OP, 5% PART B), the reimbursement reported on the claims may be over or under the actual Medicare payment amount. SQL_INFO: NUMBER(11,2) BACKGROUND : In November of 1999, it was brought to the attention of the HDUG that large reimbursement amounts were being paid in Pennsylvania. There were 75 inpatient claims provided where the reimbursement amount was over $500,000 and at least 25 times the total charge amount. These claims were processed between 9/29/98 and 10/1/98. There were also claims identified with reimbursement less than $500,000 but greater than total charge. It was later discovered that the source of the problem was an error in entering an MSA; the decimal point was off by 2 positions. Because there were no changes in utilization, the claims were corrected and the correct payments dis- tributed, but the new payment amounts were never sent to CWF (not in NCH). There is currently no requirement that FIs and carriers update CWF with final payment information by submitting payment only adjustments. It was noted that there is no expectation that CWF wll have final payment information for claims. CORRECTIVE ACTION : According to Veritus (FI), the problem was caught in their system using a pre-payment edit prior to sending out the payments. The erroneous MSA value was corrected and the claims were then sent to PRICER again and paid correctly. The claims were corrected and correct payments were made but these new payment amounts were never sent to CWF and are not reflected in the NCH. SOURCE: CONTACT : OIS/EDG/DMUDD QUERY: RIFQQ41 ON DB2T *******END OF LIMITATION APPENDIX FOR RECORD: DMERC_CLM_REC*******