CMS Pub. 100-04, ch. 27, § 80.4

A. The Mechanics of the CWF Claims Selection Process and BOI and Claim-based

Reply Trailers

1. CWF Receipt and Processing of the Coordination of Benefits Agreement Insurance File

(COIF)

Effective July 6, 2004, the Benefits Coordination & Recovery Center (BCRC) began to

send copies of the Coordination of Benefits Agreement Insurance File (COIF) to the nine

CWF host sites on a weekly basis. The COIF will contain specific information that will

identify the beneficiaries other health insurance, also known as the COBA trading partner,

including name, COBA ID, address, and tax identification number (TIN). It will also

contain each trading partner’s claims selection criteria exclusions (claim or bill types that

the trading partner does not want to receive via the crossover process) along with an

indicator (Y=Yes; N=No) regarding whether the trading partner wishes its name to be

printed on the Medicare Summary Notice (MSN).

The CWF shall load the initial COIF submission from the BCRC as well as all future

weekly updates.

Upon receipt of a claim, the CWF shall take the following actions:

a. Search for a COBA eligibility record on the BOI auxiliary record for each beneficiary,

unless there is a COBA ID in range 55000 through 55999 present on the incoming HUBC

or HUDC claim (which identifies Medigap claim-based crossover), and obtain the

associated COBA ID(s) NOTE: There may be multiple COBA IDs;

b. Refer to the COIF associated with each COBA ID (NOTE: CWF shall pull the COBA

ID from the BOI auxiliary record) to obtain the COBA trading partner’s name and claims

selection criteria;

c. Apply the COBA trading partner’s selection criteria; and

d. Transmit a BOI reply trailer 29 to the A/B MAC or DME MAC only if the claim is to be

sent, via 837 COB flat file or National Council for Prescription Drug Programs (NCPDP)

file, to the BCRC to be crossed over. (See Pub.100-04, Chap. 28, §70.6 for more

information about the claim file transmission process involving the A/B MAC or DME

MAC and the BCRC.)

Effective with the October 2004 systems release, CWF shall read the COIF submission to

determine whether a Test/Production Indicator “T” (test mode) or “P” (production mode) is

present. CWF will then include the Test/Production Indicator on the BOI reply trailer 29

that is returned to the A/B MAC or DME MAC. (See additional details below.)

Effective with July 7, 2009, at CMS’s direction, the BCRC modified the COIF so that the

“Test/Production” indicator, originally created as part of the October 2004 release, is

renamed the “4010A1 Test/Production indicator” and a new field, the “NCPDP-5.1

Test/Production indicator,” is also reflected. In turn, CWF shall 1) accept and process the

BCRC-generated modified COIF on a weekly basis; and 2) accept the following values

within the two newly defined COIF fields: “N” (format not in use for this trading partner);

“P” (trading partner in production); and “T” (trading partner in “test” mode). CWF shall

also modify the BOI reply trailer (29) to reflect these changes, as further specified under

“BOI Reply Trailer 29 Processes” below.

2. BOI Reply Trailer 29 Processes

For purposes of eligibility file-based crossover, if CWF selects a claim for crossover, it

shall return a BOI reply trailer 29 to the A/B MAC or DME MAC. The returned BOI reply

trailer 29 shall include, in addition to COBA ID(s), the COBA trading partner name(s), an

“A” crossover indicator that specifies that the claim has been selected to be crossed over,

the insurer effective and termination dates, and a 1-digit indicator [“Y”=Yes; “N”=No] that

specifies whether the COBA trading partner’s name should be printed on the beneficiary

MSN. Effective with the October 2004 systems release, CWF shall also include a 1-digit

Test/Production Indicator “T” (test mode) or “P” (production mode) on the BOI reply

trailer 29 that is returned to the A/B MAC or DME MAC.

Effective with July 7, 2009, CWF shall modify the BOI reply trailer (29) to rename the

existing Test/Production indicator as “4010A1 Test/Production indicator” and rename the

NCPDP Test/Production indicator as “NCPDPD0 Test/Production indicator.” In addition,

CWF shall include a new 1-byte field “NCPDP51 Test/Production indicator” as part of the

BOI reply trailer (29).

B. MSN Crossover Messages

Beginning with the October 2004 systems release, when an A/B MAC or DME MAC

receives a BOI reply trailer 29 from CWF that contains a Test/Production Indicator “T”

(test mode), it shall ignore the MSN Indicator provided on the trailer. Instead, the A/B

MAC or DME MAC shall follow its existing procedures for inclusion of trading partner

names on MSNs for those trading partners with whom it has existing Trading Partner

Agreements (TPAs).

Beginning with the October 2004 systems release, when an A/B MAC or DME MAC

receives a BOI reply trailer 29 from CWF that contains a Test/Production Indicator “P”

(production mode), it shall read the MSN indicator (Y=Yes, print trading partner’s name;

N=Do not print trading partner’s name) returned on the BOI reply trailer 29. (Refer to

Pub.100-4, chapter 28, §70.6 for additional details.)

Effective January 5, 2009, when CWF returns a BOI reply trailer (29) to an A/B MAC or

DME MAC that contains only a COBA ID in the range 89000 through 89999, the shared

system shall suppress all crossover information, including name of insurer and generic

message#35.1, from all beneficiary MSNs. (See chapter 28, §70.6 for details regarding

additional A/B MAC and DME MAC requirements.)

In addition, the A/B MAC or DME MAC shall not issue special provider notification

letters following its receipt of BCRC Detailed Error Reports when the claim’s associated

COBA ID is within the range 89000 through 89999 (see chapter 28, §70.6.1 for more

details.)

C. Electronic Remittance Advice (835)/Provider Remittance Advice Crossover

Messages

Beginning with the October 2004 release, when CWF returns a BOI reply trailer (29) that

contains a “T” Test/Production Indicator to the A/B MACs and DME MACs, they shall not

print information received from the BOI reply trailer (29) in the required crossover fields

on the 835 Electronic Remittance Advice or other provider remittance advice(s) that is/are

in production. A/B MACs and DME MACs shall, however, populate the 835 ERA (or

provider remittance advice(s) in production) with required crossover information when

they have existing agreements with trading partners.

Beginning with the October 2004 release, when CWF returns a BOI reply trailer (29) that

contains a “P” Test/Production Indicator to the A/B MACs and DME MACs, they shall use

the returned BOI trailer information to take the following actions on the provider’s 835

Electronic Remittance Advice:

1. Record code 19 in CLP-02 (Claim Status Code) in Loop 2100 (Claim Payment

Information) of the 835 ERA (v. 4010-A1). [NOTE: Record “20” in CLP-02 (Claim

Status Code) in Loop 2100 (Claim Payment Information) when Medicare is the

secondary payer.]

2. Update the 2100 Loop (Crossover Carrier Name) on the 835 ERA as follows:

• NM101 [Entity Identifier Code]—Use “TT,” as specified in the 835

Implementation Guide.

• NM102 [Entity Type Qualifier]—Use “2,” as specified in the 835

Implementation Guide.

• NM103 [Name, Last or Organization Name]—Use the COBA trading partner’s

name that accompanies the first sorted COBA ID returned to you on the BOI

reply trailer.

• NM108 [Identification Code Qualifier]—Use “PI” (Payer Identification.)

• NM109 [Identification Code]—Use the first COBA ID returned to you on the

BOI reply trailer. (See line 24 of the BOI aux. file record.

If the 835 ERA is not in production and the A/B MAC or DME MAC receives a “P”

Test/Production Indicator, the A/B MAC or DME MAC shall use the information provided

on the BOI reply trailer (29) to populate the existing provider remittance advices that it has

in production.

Effective January 5, 2009, if CWF returns only a COBA ID range 89000 through 89999

on a BOI reply trailer (29) to an A/B MAC or DME MAC, the associated shared system

shall suppress all crossover information (the entire 2100 loop) on the 835 ERA.

Effective October 3, 2011, when a beneficiary’s claim is associated with more than one

COBA ID (i.e., the beneficiary has more than one health insurer/benefit plan that has

signed a national COBA), CWF shall sort the COBA IDs and trading partner names in the

following order:

1) Eligibility-based Medigap (30000-54999); 2) Claim-based Medigap (55000-59999); 3)

Supplemental (00001-29999); 4) Other Insurer (80000-80213); 5) Other Insurer (80215-

88999); 6) CHAMPVA (80214); 7) TRICARE (60000-69999); 8) Medicaid (70000-

79999); and 9) Other—Health Care Pre-Payment Plan [HCPP] (89000-89999). When two

or more COBA IDs fall in the same range (see item 24 in the BOI Auxiliary File table

above), CWF shall sort numerically within the same range.

3. CWF Treatment of Non-assigned Medicaid Claims

When CWF receives a non-assigned Medicare claim for a beneficiary whose BOI auxiliary

record contains a COBA ID with a current effective date in the Medicaid eligibility-based

range (70000-77999), it shall reject the claim by returning edit 5248 to the A/B MAC (B)

shared system only when the Medicaid COBA trading partner is in production mode

(Test/Production Indicator=P) with the BCRC. At the same time, CWF shall only return a

Medicaid reply trailer 36 to the A/B MAC (B) that contains the trading partner’s COBA ID

and beneficiary’s effective and termination dates under Medicaid when the Medicaid

COBA trading partner is in production mode with the BCRC. CWF shall determine that a

Medicaid trading partner is in production mode by referring to the latest COIF update it

has received.

If, upon receipt of CWF edit 5248 and the Medicaid reply trailer (36), the A/B MAC (B)

determines that the non-assigned claim’s service dates fall during a period when the

beneficiary is eligible for Medicaid, it shall convert the assignment indicator from “non-assigned” to “assigned” and retransmit the claim to CWF. After the claim has been

retransmitted, the CWF will only return a BOI reply trailer to the A/B MAC (B) if the claim

is to be sent to the BCRC to be crossed over.

Effective with October 1, 2007, CWF shall cease returning an edit 5248 and Medicaid

reply trailer 36 to a DME MAC. In lieu of this procedure, CWF shall only return a BOI

reply trailer (29) to the DME MAC for the claim if the COBA Insurance File (COIF) for

the State Medicaid Agency indicates that the entity wishes to receive non-assigned claims.

NOTE: Most Medicaid agencies will not accept such claims for crossover purposes.

If CWF determines via the corresponding COIF that the State Medicaid Agency does not

wish to receive non-assigned claims, it shall exclude the claim for crossover. In addition,

CWF shall mark the excluded claim with its appropriate claims crossover disposition

indicator (see §80.5 of this chapter for more details) and store the claim with the

information within the appropriate Health Insurance Master Record (HIMR) detailed

history screen.

DME MACs shall no longer modify the provider assignment indicator on incoming non-assigned supplier claims for which there is a corresponding COBA ID in the ‘Medicaid’

range (70000-77999).

4. Additional Information Included on the HUIP, HUOP, HUHH, HUHC, HUBC and

HUDC Queries to CWF

Beneficiary Liability Indicators on Part B and DMAC CWF Claims Transactions

Effective with the January 2005 release, the Part B and DME MAC shared systems shall be

required to include an indicator ‘L’ (beneficiary is liable for the denied service[s]) or ‘N’

(beneficiary is not liable for the denied service[s]) in an available field on the HUBC and

HUDC queries to CWF for claims on which all line items are denied. The liability

indicators (L or N) will be at the header or claim level rather than at the line level.

Currently, the DME MAC shared system is able to identify, through the use of an internal

indicator, whether a submitted claim is in the National Council for Prescription Drug

Programs (NCPDP) format. The DME MAC shared system shall pass an indicator “P” to

CWF in an available field on the HUDC query when the claim is in the NCPDP format.

The indicator “P” shall be included in a field on the HUDC query that is separate from the

fields used to indicate whether a beneficiary is liable for all services denied on his/her

claim.

The CWF shall read the new indicators passed via the HUBC or HUDC queries for

purposes of excluding denied services on claims with or without beneficiary liability and

NCPDP claims.

Beneficiary Liability Indicators on Part A CWF Claims Transactions

Effective with October 2007, the CWF maintainer shall create a 1-byte beneficiary

liability indicator field within the header of its HUIP, HUOP, HUHH, and HUHC Part A

claims transactions (valid values for the field=L or N).

As A/B MACs (A, HHH) adjudicate claims and determine that the beneficiary has

payment liability for any part of the fully denied services or service lines, they shall set

an ‘L’ indicator within the newly created beneficiary liability field in the header of their

HUIP, HUOP, HUHH, and HUHC claims that they transmit to CWF. In addition, as A/B

MACs (A, HHH) adjudicate claims and determine that the beneficiary has no payment

liability for any of the fully denied services or service lines—that is, the provider must

absorb all costs for the fully denied claims—they shall include an ‘N’ beneficiary

indicator within the designated field in the header of their HUIP, HUOP, HUHH, and

HUHC claims that they transmit to CWF.

Upon receipt of an HUIP, HUOP, HUHH, or HUHC claim that contains an ‘L’ or ‘N’

beneficiary liability indicator, CWF shall read the COBA Insurance File (COIF) to

determine whether the COBA trading partner wishes to receive ‘original’ fully denied

claims with beneficiary liability (crossover indicator ‘G’) or without beneficiary liability

(crossover indicator ‘F’) or ‘adjustment’ fully denied claims with beneficiary liability

(crossover indicator ‘U’) or without beneficiary liability (crossover indicator ‘T’).

CWF shall deploy the same logic for excluding Part A fully denied ‘original’ and

‘adjustment’ claims with or without beneficiary liability as it now utilizes to exclude fully

denied ‘original’ and ‘adjustment’ Part B and DMEPOS claims with and without

beneficiary liability, as specified elsewhere within this section. As of January 4, 2010,

CWF shall read action code 8, in addition to action code 1, in association with incoming

fully denied original HUIP and HUOP claims. CWF shall continue to read action code 1

for purposes of excluding all other fully denied original HUHH and HUHA claims. (See

items J and K within this section for more specifics regarding revised logic for exclusion

of fully denied HUIP and HUOP adjustment claims.)

If CWF determines that the COBA trading partner wishes to exclude the claim, as per the

COIF, it shall suppress the claim from the crossover process.

CWF shall post the appropriate crossover disposition indicator in association with the

adjudicated claim on the HIMR detailed history screen (see §80.5 of this chapter).

In addition, the CWF maintainer shall create and display the new 1-byte beneficiary

liability indicator field within the HIMR detailed history screens (INPL, OUTL, HHAL,

and HOSL), to illustrate the indicator (‘L’ or ‘N’) that appeared on the incoming HUIP,

HUOP, HUHH, or HUHC claim transaction.

CWF Editing for Incorrect Values

If an A/B MAC (A, HHH) sends values other than ‘L’ or ‘N’ in the newly defined

beneficiary liability field in the header of its HUIP, HUOP, HUHH, or HUHC claim,

CWF shall reject the claim back to the A/B MAC (A, HHH) or DME MAC for correction.

Following receipt of the CWF rejection, the A/B MAC (A, HHH) shall change the

incorrect value placed within the newly defined beneficiary liability field and retransmit

the claim to CWF.

5. Modification to the CWF Inclusion or Exclusion Logic for the COBA Crossover

Process

Beginning with the October 2006 release, the CWF or its maintainer shall modify its

COBA claims selection logic and processes as indicated below. The CWF shall continue

to include or exclude all other claim types in accordance with the logic and processes that

it had in place prior to that release.

D. New A/B MAC (B) Inclusion or Exclusion Logic

The CWF shall read the first two (2) positions of the Business Segment Identifier (BSI),

as reported on the HUBC claim, to uniquely include or exclude claims from state-specific

A/B MACs (B) or DME MACs, as indicated on the COIF.

E. Exclusion of Fully Paid Claims

The CWF shall continue to exclude Part B claims paid at 100 percent by checking for the

presence of claims entry code ‘1’ and determining that each claim’s allowed amount

equals the reimbursement amount and confirming that the claim contains no denied

services or service lines.

The CWF shall continue to read action code ‘1’ and determine that there are no

deductible or co-insurance amounts for the purpose of excluding Part A original claims

paid at 100 percent. In addition, CWF shall determine that the Part A claim contained a

reimbursement amount before excluding a claim with action code ‘1’ that contained no

deductible and co-insurance amounts and that the claim contained no denied services or

service lines.

Claims with Fully Paid Lines, without Deductible or Co-insurance Remaining, and

Additional Denied Service Lines

New HUBC Line-Level Indicator Field

Effective January 4, 2010, the CWF maintainer created a new 1-byte liability denial

indicator (LIAB IND) at the service line level for individually denied claim lines in

association with the HUBC claim transaction (valid values=B or spaces).

Part B Shared System Requirements

When the Part B shared system adjudicates claims where most of the claim service detail

lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line that are the

same as the paid amounts per line and the lines do not carry deductible or co-insurance

amounts) but where some detail lines are denied, it shall take the following actions:

1) Input a “B” value in the newly created 1-byte LIAB IND field for each denied

service line where the beneficiary has payment liability (NOTE: there may be

multiple instances where the “B” value will be applied, contingent upon whether

the beneficiary is liable for each of the denied service lines);

2) Input spaces in the newly created 1-byte LIAB IND field for each denied service

line where the provider, rather than the beneficiary, is contractually liable for the

denied service; and

3) Transmit the HUBC claim to CWF for normal verification and validation

processing.

CWF Requirements

The CWF system shall modify its logic for “original” fully paid claims, without

deductible or co-insurance remaining, in association with Part B HUBC claims as

follows:

1) Continue to verify the claim’s entry or action code for confirmation that the

claim is an original;

2) Confirm that the claim contains service lines where the amount allowed per line

equals the amount paid per line;

3) Check for the presence of a “B” line LIAB IND in association with any of the

denied service lines on the claim;

4) Suppress the claim from the crossover process if the claim does not contain a

“B” line LIAB IND for any of the denied service lines; and

5) Select the claim for crossover if even one of the denied lines contains a “B” line

LIAB IND.

Upon suppressing the Part B claim from the crossover process, CWF shall annotate the

claim on the Part B claim detail (PTBH) screen with a newly created “AF” (Fully

reimbursable claim containing denied lines with no beneficiary liability) claims crossover

disposition indicator. (See § 80.5 of this chapter for more details regarding crossover

disposition indicators.)

F. Claims Paid at Greater than 100 Percent of the Submitted Charge

The CWF shall modify its current logic for excluding Part A original Medicare claims

paid at greater than 100 percent of the submitted charges as follows:

In addition to meeting the CWF exclusion criteria for Part A claims paid at greater than

100 percent of the submitted charges, CWF shall exclude these claims only when there is

no deductible or co-insurance amounts remaining on the claims.

NOTE: The current CWF logic for excluding Part B original Medicare claims paid at

greater than 100 percent of the submitted charges/allowed amount (specifically, type F

ambulatory surgical center claims, which typically carry deductible and co-insurance

amounts) shall remain unchanged.

G. Claims with Monetary or Non-Monetary Changes

The CWF shall check the reimbursement amount as well as the deductible and co-insurance amounts on each claim to determine whether a monetary adjustment change to

an original Part A, B, or DMEPOS claim occurred.

To exclude non-monetary adjustments for Part A, B, and DMEPOS claims, the CWF

shall check the reimbursement amount as well as the deductible and co-insurance

amounts on each claim to confirm that there were no monetary changes on the adjustment

claim as compared to the original claim.

Effective with April 1, 2008, the CWF shall also include total submitted/billed charges as

part of the foregoing elements used to exclude adjustment claims, monetary as well as

adjustment claims, non-monetary. (See sub-section N, “Overarching Adjustment Claim

Exclusion Logic,” for details concerning the processes that CWF shall follow when the

COBA trading partner’s COIF specifies exclusion of all adjustment claims.)

H. Excluding Adjustment Claims When the Original Claim Was Also Excluded

When the CWF processes an adjustment claim, it shall take the following action when the

COIF indicates that the “production” COBA trading partner wishes to receive adjustment

claims, monetary or adjustment claims, non-monetary:

• Return a BOI reply trailer 29 to the A/B MAC or DME MAC if CWF locates the

original claim that was marked with an ‘A’ crossover disposition indicator or if

the original claim’s crossover disposition indicator was blank/non-existent;

• Exclude the adjustment claim if CWF locates the original claim and it was

marked with a crossover disposition indicator other than ‘A,’ meaning that the

original claim was excluded from the COBA crossover process.

CWF shall not be required to search archived or purged claims history to determine

whether an original claim had been crossed over.

The CWF maintainer shall create a new ‘R’ crossover disposition indicator, as referenced

in a chart within §80.5 of this chapter, to address this exclusion for customer service

purposes. The CWF maintainer shall ensure that adjustment claims that were excluded

because the original claim was not crossed over shall be marked with an ‘R’ crossover

disposition indicator after they have been posted to the appropriate HIMR detailed history

screen.

I. Excluding Part A, B, and DME MAC Fully Paid Adjustment Claims Without

Deductible and Co-Insurance Remaining

The CWF shall apply logic to exclude Part A and Part B (including DMEPOS)

adjustment claims (identified as action code ‘3’ for Part A claims and entry code ‘5’ for

Part B and DMEPOS claims) when the COIF indicates that a COBA trading partner

wishes to exclude adjustment claims that are fully paid and without deductible or co-insurance amounts remaining.

Effective with October 1, 2007, CWF developed logic as follows to exclude fully paid

Part A adjustment claims without deductible and co-insurance remaining:

1) Verify that the claim contains action code ‘3’;

2) Verify that there are no deductible and co-insurance amounts on the claim;

3) Verify that the reimbursement on the claim is greater than zero; and

4) Confirm that the claim contains no denied services or service lines.

Special Note: Effective with October 1, 2007, CWF ceased by-passing the logic to

exclude Part A adjustments claims fully (100 percent) paid in association with home

health prospective payment system (HHPPS) types of bills 329 and 339. The CWF shall

exclude such claims if the COIF designates that the trading partner wishes to exclude

“adjustment claims fully paid without deductible or co-insurance remaining” or if these

bill types are otherwise excluded on the COIF.

The CWF shall develop logic as follows to exclude Part B or DMEPOS fully paid

adjustment claims without deductible or co-insurance remaining:

1) Verify that the claim contains an entry code ‘5’;

2) Verify that the allowed amount equals the reimbursement amount; and

3) Confirm that the claim contains no denied services or service lines.

The CWF maintainer shall create a new ‘S’ crossover disposition indicator for adjustment

claims that are paid at 100 percent. The CWF maintainer shall ensure that excluded

adjustment claims that are paid at 100 percent shall be marked with an ‘S’ crossover

disposition indicator after they have been posted to the appropriate HIMR detailed history

screen. In addition, the CWF maintainer shall add “Adj. Claims-100 percent PD” to the

COBA Insurance File Summary screen (COBS) on HIMR so that this exclusion will be

appropriately displayed for customer service purposes.

Claims with Fully Paid Lines, without Deductible or Co-insurance Remaining, and

Additional Denied Service Lines

New HUBC Line-Level Indicator Field

Effective January 4, 2010, the CWF maintainer created a new 1-byte LIAB IND at the

service line level for individually denied claim lines in association with the HUBC claim

transaction (valid values=B or spaces).

Part B Shared System Requirements

When the Part B shared system adjudicates adjustment claims where most of the claim

service detail lines are fully [or 100 percent] paid (i.e., contain allowed amounts per line

that are the same as the paid amounts per line and the lines do not carry deductible or co-insurance amounts) but where some detail lines are denied, it shall take the following

actions:

1) Input a “B” value in the newly created 1-byte LIAB IND field for each denied

service line where the beneficiary has payment liability (NOTE: there may be

multiple instances where the “B” value will be applied, contingent upon

whether the beneficiary is liable for each of the denied service lines);

2) Input spaces in the newly created 1-byte LIAB IND field for each denied

service line where the provider, rather than the beneficiary, is contractually

liable for the denied service; and

3) Transmit the HUBC claim to CWF for normal verification and validation

processing.

CWF Requirements

The CWF system shall modify its logic for “adjustment” fully paid claims, without

deductible or co-insurance remaining, in association with Part B HUBC claims as

follows:

1) Continue to verify the claim’s entry or action code for confirmation that the claim

is an adjustment;

2) Where applicable, also continue to check additionally to determine if the

incoming claim contains entry code 5 or an “R” recovery audit contractor (RAC)

adjustment indicator, as directed in previous CMS instructions;

3) Where applicable, continue to check additionally to determine if the incoming

claim contains an entry or action code value of “1,” along with Claim Adjustment

Indicator=A, as per previous CMS direction;

4) Confirm that the claim contains service lines where the amount allowed per line

equals the amount paid per line;

5) Check for the presence of a “B” line LIAB IND in association with any of the

denied service lines on the claim;

6) Suppress the claim from the crossover process if the claim does not contain a “B”

line LIAB IND for any of the denied service lines; and

7) Select the claim for crossover if even one of the denied lines contains a “B” LIAB

IND.

Upon suppressing the Part B claim from the crossover process, CWF shall annotate the

claim on the Part B claim detail (PTBH) screen with a newly created “AF” (Fully

reimbursable claim containing denied lines with no beneficiary liability) claims crossover

disposition indicator. (See § 80.5 of this chapter for more details regarding crossover

disposition indicators.)

J. Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied

with No Additional Liability

The CWF shall apply logic to exclude Part A and Part B (including DMEPOS) fully

denied adjustment claims that carry no additional beneficiary liability when the COIF

indicates that a COBA trading partner wishes to exclude such claims.

Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment claim

(action code ‘3’) where the entire claim is denied and the beneficiary has no additional

liability. As of January 4, 2010, that logic was changed to also include the reading of

action code 8, in addition to action code 3, for HUIP and HUOP claims. The revised

logic will thus be as follows:

1) Verify that the claim was sent as action code ‘3’;

2) Verify also if an HUIP or HUOP claim contains action code ‘8’ rather than

an action code ‘3’; and

3) Check for the presence of an ‘N’ beneficiary liability indicator in the

header of the fully denied claim. (See the “Beneficiary Liability Indicators on

Part A CWF Claims Transactions” section above for additional information.)

The CWF shall apply logic to the Part B and DMEPOS adjustment claims (entry code

‘5’) where the entire claim is denied and the beneficiary has no additional liability as

follows:

1) Verify that the claim was sent as entry code ‘5’; and

2) Check for the presence of an ‘N’ liability indicator on the fully denied claim.

The CWF maintainer shall create a new ‘T’ crossover disposition indicator for adjustment

claims that are 100 percent denied with no additional beneficiary liability. The CWF

maintainer shall ensure that excluded adjustment claims that were entirely denied and

contained no beneficiary liability shall be marked with a ‘T’ crossover disposition

indicator after they have been posted to the appropriate HIMR detailed history screen. In

addition, the CWF maintainer shall add “Denied Adjs-No Liab” to the COBS on HIMR

so that this exclusion will be appropriately displayed for customer service purposes.

K. Excluding Part A, B, and DME MAC Adjustment Claims That Are Fully Denied

with No Additional Liability

The CWF shall apply logic to exclude Part A and Part B (including DMEPOS) fully

denied adjustment claims that carry additional beneficiary liability when the COIF

indicates that a COBA trading partner wishes to exclude such claims.

Effective with October 1, 2007, the CWF shall apply logic to the Part A adjustment claim

(action code ‘3’) where the entire claim is denied and the beneficiary has additional

liability. As of January 4, 2010, that logic shall be changed to also include the reading of

action code 8, in addition to action code 3, for HUIP and HUOP claims. The revised

logic will thus be as follows:

1) Verify that the claim was sent as action code ‘3’;

2) Verify also if an HUIP or HUOP claim contains action code ‘8’ rather than an

action code ‘3’; and

3) Check for the presence of an ‘L’ beneficiary liability indicator in the header of the

fully denied claim. (See the “Beneficiary Liability Indicators on Part A CWF

Claims Transactions” section above for additional information.)

The CWF shall apply logic to exclude Part B and DMEPOS adjustment claims (entry

code ‘5’) where the entire claim is denied and the beneficiary has additional liability as

follows:

1) Verify that the claim was sent as entry code ‘5’; and

2) Check for the presence of an ‘L’ liability indicator on the fully denied claim.

The CWF maintainer shall create a new ‘U’ crossover disposition indicator for

adjustment claims that are 100 percent denied with additional beneficiary liability. The

CWF maintainer shall ensure that excluded adjustment claims that were entirely denied

and contained beneficiary liability shall be marked with a ‘U’ crossover disposition

indicator after they have been posted to the appropriate HIMR detailed history screen. In

addition, the CWF maintainer shall add “Denied Adjs-Liab” to the COBS on HIMR so

that this exclusion will be appropriately displayed for customer service purposes.

L. Excluding MSP Cost-Avoided Claims

The CWF shall develop logic to exclude MSP cost-avoided claims when the COIF

indicates that a COBA trading partner wishes to exclude such claims.

The CWF shall apply the following logic to exclude Part A MSP cost-avoided claims:

• Verify that the claim contains one of the following MSP non-pay codes:

E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18,

25, and 26.

The CWF shall apply the following logic to exclude Part B and DMAC MSP cost-avoided claims:

• Verify that the claim contains one of the following MSP non-pay codes:

E, F, G, H, J, K, Q, R, T, U, V, W, X, Y, Z, 00, 12, 13, 14, 15, 16, 17, 18,

25, and 26.

The CWF maintainer shall create a new ‘V’ crossover disposition indicator for the

exclusion of MSP cost-avoided claims. The CWF maintainer shall ensure that excluded

MSP cost-avoided claims shall be marked with a ‘V’ crossover disposition indicator after

they have been posted to the appropriate HIMR detailed history screen. In addition, the

CWF maintainer shall add “MSP Cost-Avoids” to the COBS on HIMR so that this

exclusion will be appropriately displayed for customer service purposes.

M. Excluding Sanctioned Provider Claims from the COBA Crossover Process

Effective with April 2, 2007, the CWF maintainer created space within the HUBC claim

transaction for a newly developed ‘S’ indicator, which designates ‘sanctioned provider.’

A/B MACs (B) that process claims from physicians (e.g., practitioners and specialists) and

suppliers (independent laboratories and ambulance companies) shall set an ‘S’ indicator

in the header of a fully denied claim if the physician or supplier that is billing is

suspended/sanctioned. NOTE: Such physicians or suppliers will have been identified by

the Office of the Inspector General (OIG) and will have had their Medicare billing

privileges suspended. Before setting the ‘S’ indicator in the header of a claim, the A/B

MAC (B) shall first split the claim it is contains service dates during which the provider is

no longer sanctioned. This will ensure that the A/B MAC (B) properly sets the ‘S’

indicator for only those portions of the claim during which the provider is sanctioned.

Upon receipt of an HUBC claim that contains an ‘S’ indicator, the CWF shall exclude the

claim from the COBA crossover process. The CWF therefore shall not return a BOI

reply trailer 29 to the A/B MAC (B) for any HUBC claim that contains an ‘S’ indicator.

N. Overarching Adjustment Claim Exclusion Logic

“Overarching adjustment claim logic” is defined as the logic that CWF will employ,

independent of a specific review of claim monetary changes, when a COBA trading

partner’s COIF specifies that it wishes to exclude all adjustment claims.

Modified CWF Logic

Effective with April 1, 2008, the CWF maintainer shall change its systematic logic to

accept a new version of the COIF that now features a new “all adjustment claims”

exclusion option.

For the COBA eligibility file-based crossover process, where CWF utilizes both the BOI

auxiliary record and the COIF when determining whether it should include or exclude a

claim for crossover, CWF shall apply the overarching adjustment claim logic as follows:

• Verify that the incoming claim has an action code of 3 or entry code of 5 or, if

the claim has an action or entry code of 1 (original claim), confirm whether it

has an “A” claim header value, which designates adjustment claim for

crossover purposes; and

• Verify that the COIF contains a marked exclusion for “all adjustment claims.”

If these conditions are met, CWF shall exclude the claim for crossover under

the COBA eligibility file-based crossover process.

If both of these conditions are met, CWF shall exclude the claim for crossover under the

COBA eligibility file-based crossover process. IMPORTANT: Independent of the

foregoing requirements, CWF shall continue to only select an adjustment claim for

COBA crossover purposes if: 1) it locates the matching original claim; and 2) it

determines that the original claim was selected for crossover (see “H. Excluding

Adjustment Claims When the Original Claim Was Also Excluded” above for more

information).

New Crossover Disposition Indicator

Upon excluding the claim, CWF shall mark the claim as it is stored on the appropriate

HIMR claim detail history screen with a newly developed “AC” crossover disposition

indicator, which designates that CWF excluded the claim because the COBA trading

partner wished to exclude all adjustment claims. (See §80.5 of this chapter for a

description of this crossover disposition indicator.)

The CWF shall display the new indicator within the “eligibility file-based crossover”

segment of the HIMR detailed claim history screen.

Exception Concerning COBA IDs in the Medigap Claim-based Range

CWF shall never apply the new overarching adjustment claim exclusion logic to

incoming HUBC or HUDC claims whose field 34 (“Crossover ID”) header value falls

within the range of 0000055000 to 0000059999, which represents the COBA identifier of

a COBA Medigap claim-based crossover recipient, and for which there is not a

corresponding BOI auxiliary record that likewise contains that insurer identifier. (See

§80.7 of this chapter for more information concerning the COBA Medigap claim-based

crossover process.)

O. Exclusion of Claims Containing Placeholder National Provider Identifier (NPI)

Values

Effective October 6, 2008, the CWF maintainer created space within the header of its

HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a new 1-byte

“NPI-Placeholder” field (acceptable values=Y or space).

In addition, the CWF maintainer shall create space within page two (2) of the HIMR

detail of the claim screen for 1) a new category “COBA Bypass”; and 2) a 2-byte field for

the indicator “BN,” which shall designate that CWF auto-excluded the claim because it

contained a placeholder provider value (see §80.5 of this chapter for more details

regarding the “BN” bypass indicator).

NOTE: With the implementation of the October 2008 release, the CWF maintainer shall

remove all current logic for placeholder provider values with the implementation of this

new solution for identifying claims that contain placeholder provider values.

As MACs adjudicate non VA MRA claims that fall within any of the NPI placeholder

requirements, their shared system shall take the following combined actions:

1) Input a “Y” value in the newly created “NPI Placeholder” field on the HUIP, HUOP,

HUHH, HUHC, HUBC, or HUDC claim transaction if a placeholder value exists on or is

created anywhere within the SSM claim record (NOTE: Shared systems shall include

spaces within the “NPI Placeholder” field when the claim does not contain a placeholder

NPI value); and

2) Transmit the claim to CWF, as per normal requirements.

Upon receipt of claims where the NPI Placeholder field contains the value “Y,” CWF

shall auto-exclude the claim from the national COBA crossover process. In addition,

CWF shall populate the value “BN” in association with the newly developed “COBA

Bypass” field on page 2 of the HIMR Part B and DME MAC claim detail screens and on

page 3 of the HIMR A/B MAC (A) claim detail screen.

P. Excluding Physician Quality Reporting System (PQRS) Only Codes Reported on

837 Professional Claims

Effective October 6, 2008, the CWF maintainer shall create space within the header of its

HUBC claim transmission for a 1-byte PQRS indicator (valid values=Q or space).

In addition, CWF shall create a 2-byte field on page 2 of the HIMR claim detail in

association with the new category “COBA Bypass” for the value “BQ,” which shall

designate that CWF auto-excluded the claim because it contained only PQRS codes (see

§80.5 of this chapter for more details regarding the bypass indicator).

Prior to transmitting the claim to CWF for normal processing, MCS shall input the value

“Q” in the newly defined PQRS field in the header of the HUBC when all service lines on

a claim contain PQRI (status M) codes.

Upon receipt of a claim that contains a “Q” in the newly defined PQRS field (which

signifies that the claim contains only PQRS codes on all service detail lines, CWF shall

auto-exclude the claim from the national COBA eligibility file-based and Medigap claim-based crossover processes. Following exclusion of the claim, CWF shall populate the

value “BQ” in association with the newly developed “COBA Bypass” field on page 2 of

the HIMR Part B claim detail screen.

Q. CWF Requirements for Health Care Pre-Payment Plans (HCPPs) that Receive

Crossover Claims

Effective January 5, 2009, at CMS’s direction, the BCRC assigned all HCPP COBA

participants a unique 5-byte COBA ID that falls within the range 89000 through 89999.

The CWF system shall accept the reporting of this COBA ID range. (Refer to chapter 28,

§70.6 for MAC requirements in association with HCPP and HMO cost plan crossovers.)

R. Inclusion or Exclusion of Part A Claims By Provider Identification Number (ID)

as well as Provider State

Since July 2004, the CWF has read the incoming BCRC-created COIF to determine each

national COBA trading partner’s specific claims selection as tied to each COBA ID. To

accommodate the inclusion or exclusion of Part A specific provider identifiers (IDs),

CWF currently reads the numeric value reported on the COIF by COBA ID and then

interrogates the “Provider ID,” CMS Certification Number (CCN) reported on the

incoming HUIP, HUOP, HUHH, or HUHC claims transaction. For instances where a

match is found, CWF either includes or excludes the claim from the national crossover

process, in accordance with the “I” or “E” indicator that precedes the provider ID value

reported beginning with field 225 of the COIF.

Also, since July 2004, CWF has read the 2-digit state code as referenced on the COIF as

a basis for including or excluding Part A claims by provider state. In performing this

function, CWF locates the incoming “Provider ID” on the HUIP, HUOP, HUHH, or

HUHC claims transaction and determines if the first 2 bytes match the 2-byte state code

on the BCRC-created COIF. If a match is found, CWF either includes or excludes the

claim based upon the “I” or “E” value reported in field 224 of the COIF.

Effective April 4, 2011, upon its receipt of either a 6-byte CMS Certification Number

(CCN) or a 10-digit NPI, as found starting in position 225 of the COIF, CWF shall check

both the “Provider ID” and “NPI” fields of the incoming HUIP, HUOP, HUHH, or

HUHC for potential matches. If CWF finds a provider ID or NPI match, it shall either

include or exclude the claim based upon the indicator (I or E) reported in field 224 of the

COIF.

The CWF shall continue to either 1) include the claim if the “I” indicator precedes the

provider ID or NPI reported on the COIF or 2) exclude the claim and annotate Part A

claims history with crossover indicator “K” when the reported provider ID or NPI on the

COIF is identified for exclusion from the crossover process. (See §80.5 of this chapter for

more information concerning the “K” crossover disposition indicator.)

S. Excluding Fully Denied Claims Adjudicated With An “Other Adjustment”

(OA”) Claim Adjustment Segment Group Code

Effective October 4, 2010, the CWF maintainer created space within the header of its

HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions for a 1-byte

Claim Adjustment Segment (CAS) Group Code Indicator field (valid values=G or space).

In addition, CWF developed a new 2-byte “BG” COBA By-pass indicator, which

designates that CWF auto-excluded the claim because it was adjudicated with an “OA”

CAS group code for all denied lines or services.

Prior to transmitting their adjudicated claims to CWF for normal processing, all shared

systems shall input the value “G” in the newly defined 1-byte CAS Group Code Indicator

field in the header of their HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claims when

all services or claim detail service lines on the affected claims are denied with Group

Code “OA.”

Upon receipt of a claim that contains a “G” in the newly defined CAS Group Code

Indicator field, CWF shall auto-exclude the claim from the national COBA eligibility

file-based and Medigap claim-based crossover processes. (NOTE: CWF shall not be

required to read the COIF to determine COBA trading partner preferences for claims

containing either an “L” or “N” beneficiary liability indicator when the incoming claim

contains a “G” in the newly defined CAS Group Code Indicator field.)

Following auto-exclusion of the claim, CWF shall take the following actions:

1) Annotate the claim with a “BG” COBA bypass indicator; and

2) Display the “BG” indicator as part of the COBA Bypass segment on page 3 of the

appropriate HIMR claim detail screen.

Effective with October 3, 2011, CWF created a consistency edit that will activate when

the shared systems send HUBC, HUDC, HUIP, HUOP, HUHH, and HUHC claims to

CWF that contain a value in the CAS Group Code Indicator field other than G or spaces.

Upon receipt of this consistency edit, the shared system shall take the following actions:

1) Modify the value reported in the CAS Group Code Indicator either to a “G,”

if appropriate, or spaces; and

2) Retransmit the claim to CWF.

T. New Requirements for Other Federal Payers

Effective with October 3, 2011, the CWF maintainer expanded its logic for “Other

Insurance,” which is COIF element 176, to include TRICARE for Life (COBA ID 60000-

69999) and CHAMPVA (COBA ID 80214), along with State Medicaid Agencies (70000-

79999), as entities eligible for this exclusion.

Through these changes, if either TRICARE for Life or CHAMPVA wishes to invoke the

“Other Insurance” exclusion, and if element 176 is marked on the COIF for these entities,

CWF shall suppress claims from the national COBA crossover process if it determines

that the beneficiary has active additional supplemental coverage.

As part of this revised “Other Insurance” logic for TRICARE and CHAMPVA, CWF

shall interpret “additional supplemental coverage” as including entities whose COBA

identifiers fall in any of the following ranges:

00001-29999 (Supplemental);

30000-54999 (Medigap eligibility-based);

80000-80213 (Other Insurer); and

80215-88999 (Other Insurer).

The “Other Insurance” logic for State Medicaid Agencies includes all of the following

COBA ID ranges:

00001-29999 (Supplemental);

30000-54999 (Medigap eligibility-based);

60000-69999 (TRICARE);

80000-80213 (Other Insurance)

80214 (CHAMPVA)

80215-88999 (Other Insurer).

NOTE: As of October 3, 2011, CWF shall now omit COBA ID range 89000-89999 as

part of its Other Insurance logic for State Medicaid Agencies.

CWF shall mark claims that it excludes due to “Other Insurance” with crossover

disposition indicator “M” when storing them within the CWF claims history screens.

(See §80.5 of this chapter for additional information concerning this indicator.)

U. CWF and Shared Systems Handling of Claims Where Principal Diagnosis Is “E”

Code or Equivalent Code in Successive ICD Diagnosis Versions

Effective April 1, 2013, CWF created a new 1-byte “First Reported DX Code Indicator”

field within the header of incoming HUBC and HUDC claims transactions. CWF shall

only accept “Y” or spaces as valid values for the newly created First Reported DX Code

Indicator within the header of incoming HUBC and HUDC claims and shall develop

consistency edits to address invalid values submitted in the newly created field.

For applicable situations where claims having a principle (first-listed) “E” ICD-9 code or,

when ICD-10 diagnosis coding is implemented, equivalent V00--Y99 ICD-10 diagnosis

code are either not rejected due to front-end editing or are returned as unprocessable, the

Part B and DME MAC shared systems shall:

• Input a “Y” indicator in the First Reported DX Code field (header) of the HUBC

and HUDC claims; and

• Transmit the affected claims to CWF for normal processing.

The shared systems shall have the ability to react to CWF consistency edits received

when invalid values are entered in the newly created DX Code Indicator field.

Upon receipt of claims that contain a “Y” in First Reported DX Code Indicator field,

CWF shall by-pass the claims from crossing over. CWF shall create a new “BX” COBA

by-pass indicator that it will apply to claims where a “Y” is present within the DX Code

Indicator field (See §80.5 of this chapter for more information regarding the new

indicator). Additionally, CWF shall display the new by-pass indicator on the appropriate

page(s) of the HIMR claims detail screens.