CMS Pub. 100-04, ch. 27, § 80.6

Requirements

(Rev. 13314; Issued: 07-24-25; Effective: 01-01-26; Implementation: 01-05-26)

1. Developing a Capability to Exclude Mass Adjustment Claims Tied to the Medicare

Physician Fee Schedule Updates and Mass Adjustment Claims-Other

Effective with July 2, 2007, the CWF maintainer created a new header field for a one (1)-

byte mass adjustment indicator within its HUBC, HUDC, HUOP, HUHH, and HUHC

claims transactions. The valid values for the newly created field shall be ‘M’—mass

adjustment claim-Medicare Physician Fee Schedule (MPFS) and ‘O’—mass adjustment

claim-other. Further, effective with that date, the BCRC shall send the CWF host sites a

modified COIF that contains two new claims exclusion categories: mass adjustments-MPFS and mass adjustments-other.

Effective January 5, 2026, the CWF maintainer shall accept the new one (1)-byte Mass

Adjustment Indicator value of “N” (defined as Affordable Care Act (ACA) mass

adjustment) within the header of its HUIP, HUOP, HUHH, and HUHC claims

transactions. Additionally, the CWF maintainer shall modify Part A consistency edit 0045

to accept the new Mass Adjustment indicator value of "N." Thus, effective January 5, 2026,

the valid values for the Mass Adjustment Indicator field will include N, as well as M and

O.

Upon receipt of a claim that contains an “N” or “O” indicator in the header of an HUIP,

HUOP, HUHH, and HUHC claim, CWF shall read the COIF to determine if the COBA

trading partner wishes to exclude “mass adjustment claim--other.” If CWF determines

that the trading partner wishes to exclude the mass adjustment claim--other, it shall

exclude the claim from the COBA crossover process.

Upon receipt of a claim that contains an ‘M’ indicator (new field) in the header of an

HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim, CWF shall read the COIF to

determine whether the COBA trading partner wishes to exclude the claim. If CWF

determines that the trading partner wishes to exclude the mass adjustment-MPFS claim, it

shall exclude the claim from the COBA crossover process.

Upon receipt of a claim that contains an ‘O’ indicator in the header of an HUBC, HUDC,

HUIP, HUOP, HUHH, or HUHC claim, which designates ‘mass adjustment claim-other,’

the CWF shall read the COIF to determine whether the COBA trading partner wishes to

exclude the claim. If CWF determines that the trading partner wishes to exclude mass

adjustment claims-other, it shall exclude the claim from the COBA crossover process.

Creation of New Crossover Disposition Indicators

In relation to its receipt of a claim that has either an ‘M’ or an ‘O’ header value, the CWF

shall create two new crossover disposition indicators ‘W’ (“mass adjustment claim-MPFS)

and ‘X’ (“mass adjustments claim-other excluded”) on the HIMR detailed history screens

in association with excluded processed claims for ‘production’ COBA trading partner.

Effective January 5, 2026, CWF shall associate Mass Adjustment Indicator value “N” with

COBA crossover disposition indicator ‘X.”

The CWF shall display each of the new crossover disposition indicators appropriately in

association with the processed mass adjustment claim-MPFS on the HIMR detailed history

screen. (See §80.5 of this chapter for further information.) In addition, the CWF

maintainer shall develop and display two (2) new exclusion fields within the COBA

Inquiry Screen (COBS) for ‘mass adj.-M’ (mass adjustments-MPFS) and ‘mass adj.-O’

(mass adjustments-other).

2. Developing a Capability to Treat Entry Code ‘5’ and Action Code ‘3’ Claims As

Recycled ‘Original’ Claims For Crossover Purposes

Effective July 2007, the CWF maintainer shall create a new header field within its

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

adjustment indicator (valid values= ‘N’--non adjustment claim for crossover purposes;

‘A’--adjustment claim for crossover purposes; or spaces).

In instances when CWF returns an error code 5600 to an A/B MAC or DME MAC,

thereby causing it to reset the claim’s entry code to ‘5’ to action code to ‘3,’ the A/B

MAC or DME MAC shall set a newly developed ‘N’ non-adjustment claim indicator

(‘treat as an original claim for crossover purposes’) in the header of the HUBC, HUDC,

HUIP, HUOP, HUHH, HUIP, HUOP, HUHH, and HUHC claim in the newly defined

field before retransmitting the claim to CWF. The A/B MAC or DME MAC’s system

shall then resend the claim to CWF.

Upon receipt of a claim that contains entry code ‘5’ or action code ‘3’ with a non-adjustment claim header value of ‘N,’ the CWF shall treat the claim as if it were an

‘original’ claim (i.e., as entry code ‘1’ or action code ‘1’) for crossover inclusion or

exclusion determinations. If CWF subsequently determines that the claim meets all other

inclusion criteria, it shall mark the claim with an ‘A’ (“claim was selected to be crossed

over”) crossover disposition indicator.

Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF

Beneficiary Other Insurance (BOI) Reply Trailer 29 for Such Claims

Upon receipt of a Beneficiary Other Insurance (BOI) reply trailer (29) for the recycled

claim, the A/B MAC or DME MACs’ systems shall ensure that, as part of their 837 flat

file creation processes, they populate the 2300 loop CLM05-3 (Claim Frequency Type

Code) segment with a value of ‘1’ (original). In addition, the shared systems shall ensure

that, as part of their 837 flat file creation process, they do not create a corresponding 2330

loop REF*T4*Y segment, which typically signifies ‘adjustment.’

3. Developing a Capability to Treat Claims with Non-Adjustment Entry or Action

Codes as Adjustment Claims For Crossover Purposes

In instances where A/B MACs and DME MACs must send adjustment claims to CWF as

entry code ‘1’ or action code ‘1’ (situations where the accrete claim cannot be processed

at CWF), they shall set an ‘A’ indicator in a newly defined field within the header of the

HUBC, HUDC, HUIP, HUOP, HUHH, or HUHC claim.

Upon receipt of a claim that contains entry code ‘1’ or action code ‘1’ with a claim

adjustment indicator value of ‘A,’ the CWF shall take the following actions:

• Verify that, as per the COIF, the COBA trading partner wishes to exclude

either adjustments, monetary or adjustments, non-monetary, or both; and

• Suppress the claim from crossover if the COBA trading partner wishes to

exclude either adjustments, monetary or adjustments, non-monetary, or both.

(NOTE: The expectation is that such claims do not represent mass adjustments tied to

the MPFS or mass adjustments-other.)

By Passing of Logic to Exclude Adjustment Claim if Original Claim was Not

Crossed Over

For purposes of excluding entry code ‘1’ or action code ‘1’ claims that contain an ‘A’

adjustment indicator value, CWF shall 1) assume that the ‘original’ claim that was purged

from its online history was crossed over, and 2) bypass its logic for crossover disposition

indicator ‘R’ (cross the adjustment claim over only if the original claim was previously

crossed over). Refer to §80.4 of this chapter for further details regarding this logic.

Actions to Take When A/B MAC or DME MACs Send Invalid Values

If A/B MAC or DME MAC sends claim adjustment indicator values other than ‘N,’ ‘A,’

or space within the newly designated header field within their HUBC, HUDC, HUIP,

HUOP, HUHH, and HUHC claims to CWF, CWF shall apply an edit to reject the claim

back to the A/B MAC or DME MAC. Upon receipt of the CWF rejection edit, the shared

systems shall correct the invalid value and retransmit the claim to CWF for verification

and validation.

Creation of a New Crossover Disposition Indicator For This Scenario

In relation to its receipt of a claim that has an ‘A’ header value, the CWF shall create a new

crossover disposition indicator ‘Y’ (“archived adjustment claim-excluded”) on the HIMR

detailed history screens in association with excluded processed claims for ‘production’

COBA trading partners. The CWF shall display the new ‘Y’ crossover disposition

indicator in association with the processed mass adjustment claim-MPFS on the HIMR

detailed history screen. (See §80.5 of this chapter for further information.)

Additional A/B MAC or DME MAC Requirements Following Receipt of a CWF

Beneficiary Other Insurance (BOI) Reply Trailer 29

If A/B MACs or DME MACs receive a BOI reply trailer (29) on a claim that had an ‘A’

indicator set in its header, the A/B MAC or DME MACs’ systems shall ensure that, as

part of their 837 flat file creation processes, they populate the 2300 loop CLM05-3

(‘Claim Frequency Type Code’) segment with a value that designates ‘adjustment’ rather

than ‘original’ to match the 2330B loop REF*T4*Y that they create to designate

‘adjustment claim.’

If a given shared system does not presently create a loop 2330B REF*T4*Y to designate

adjustments, it shall not make a change to do so as part of this instruction.