CMS Pub. 100-04, ch. 3, § 180.1

Records

(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)

Once the excepted/nonexcepted care determination is made, the non-specialty contractor

resubmits the claim to CWF using the following indicators to record the determination:

• Indicator “1” - for excepted care; or

• Indicator “2” - for nonexcepted care.

NOTE: Indicator 0 (zero) presents no entry.

The following are the fields and locations for the excepted and nonexcepted indicators on

the CWF record types:

Record Location Field Size

HUIP (IP hospital/SNF Claim) 84 1 823

HUOP (Outpatient) 64 1 778

HUHC (Hospice) 64 1 778

HUHH (Home Health) 64 1 778

HUBC (A/B MAC (B) Claim) 13 1 57

The screen field corresponding to these CWF fields may vary depending on the Medicare

shared system in use at a contractor’s location. Non-specialty contractors may contact

their shared system maintainer if necessary to determine the correct screen location to use

for excepted/nonexcepted care indicators.

If a claim is resubmitted with a “0” excepted care indicator in error, CWF will again reject

the claim. Upon receipt of the resubmitted claim with a valid “1” or “2” entry, CWF will

approve it for payment and revoke the beneficiary’s election if the care received was

nonexcepted. CWF will not notify either the specialty contractor or the non-specialty

contractor of any revocations as a result of claims received for nonexcepted care. Any

subsequent RNHCI claims processed at the contractor with RNHCI specialty workload

will be not approved for payment by CWF unless the beneficiary files a new election

following the prescribed time intervals between elections.

If development to make the excepted/nonexcepted care determination discovered that the

beneficiary paid out of pocket for the services and the claim for payment for medical care must

be denied as a result.

The following reflects the remittance advice messages and associated codes that will

appear when rejecting/denying claims under this policy. This CARC/RARC combination

is compliant with CAQH CORE Business Scenario 3.

Group Code: PR

CARC: 96

RARC: MA47

MSN: N/A