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(DDE) User`s Manual

1. H Black Lung Veteran s Administration Program Occurrence Codes Date Definition 1 or 2 Date is the effective date of applicable program involvement A E Date is the date of previous claim where Medicare was determined to be secondary ESRD CD DATE The home dialysis method and effective date in MMDDCCYY format Valid values are 1 Beneficiary elects to receive all supplies and equipment for home dialysis from an ESRD facility and the facility submits the claim 2 Beneficiary elects to deal directly with one supplier for home dialysis supplies and equipment and beneficiary submits claim to Carrier Cat Data PSYCH The remaining lifetime psychiatric days DISCHG Last or through discharge date in MMDDYY format IND Identifies whether the discharge date is an interim date Valid values are 0 Initialized 1 Interim DAYS USED The number of pre entitlement psychiatric days used by the beneficiary patient BLOOD The number of blood pints carried over from 1988 to 1989 Days Information 2 occurrences YR The catastrophic trailer year APP Identifies whether a December inpatient stay has been applied to the current year deductible MET The remaining inpatient hospital deductible BLD The remaining blood deductible CO The remaining skilled nursing facility coinsurance days FL Number of full SNF days remaining FRM The From Date of the earliest processed bill TO The
2. Field Name X Ref Description DCN The document control number assigned to the claim HIC 60 The patient s Medicare number as shown on the Medicare card RECEIPT DATE The date the claim was received into the Medicare claims processing system Not required for new claims entry TOB 4 This field shows the type of bill being submitted STATUS The current status of the claim New claim entries will display S LOCATION The current location of the claim in the system New claim entries will display BO100 until F9 is pressed TRAN DT This field displays the transaction date Not displayed on new claim entries STMT COV 6 The statement cover dates entered on MAP1711 DT TO UTN Unique Tracking Number UTN This is a 14 digit field that identifies the UTN submitted on the claim in the Medicare Treatment Authorization field The UTN is submitted on claims that require prior authorization See figure 47 regarding the Treatment Authorization field PROG Program Indicator This field identifies the Prior Authorization Program ID matching to the item services submitted on the claim This is a four digit alpha numeric field The valid format is ANNN or HNNN Palmetto GBA Page 74 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description CAH Critical Access Hospital CAH Incentive Indicator This field identifies whether a claim line is eligible for a specif
3. Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code EPISODE The start date of a home health episode START EPISODE END The end date of a home health episode DOEBA Date of Earliest Billing Action the first service date of the HHPPS period DOLBA Date of Last Billing Action the last service date of the HHPPS period Palmetto GBA September 2015 Page 132 Section 8 Health Insurance Query DDE User s Manual HIQA Pages 6 and 7 Field descriptions for Page6 and 7 of the HIQA screens are provided in the table following Figure 72 HIQACOP CWF PART INQUIRY REPLY PAGE 06 OF 19 IP REC CN NM IT DB INT 11004 PREVENTIVE SERVICE TECH DTE PROF DTE MMDDCCYY MMDDCCYY 80061 01012005 01012005 82465 01012005 01012005 82718 01012005 01012005 84478 01012005 01012005 G0104 04022002 04022002 G0105 01011998 01011998 PREVENTIVE SERVICE TECH DTE MMDDCCYY PCB EXAM G0101 07012001 PV 90732 90669 90670 VACCINTD PROSTATE G0102 GDRNOELG PROSTATE G0103 GDRNOELG PAP TEST 00091 07012005 CARDIOVASC CARDIOVASC CARDIOVASC CARDIOVASC COLORECTAL COLORECTAL DIABETES 82947 01012005 COLORECTAL G0106 04022002 04022002 DIABETES 82950 01012005
4. NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCY Y SX Sex Beneficiary s sex code IN Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA PN Provider Number The facility s six digit Medicare provider number APP Applicable Date Used for spell determination REAS Reason Code Indicates the reason for the inquiry that was entered on the initial inquiry screen see Figure 65 DATETIME Date and Time Stamp date and time of the inquiry in Julian date format REQ Requestor ID auto populates DISP CODE Disposition Code Indicates a condition on a CABLE response Valid values are 01 Part A Inquiry approved 02 Part A Inquiry approved 03 Part A Inquiry rejected 20 Qualified approval but may require further investigation 25 Qualified approval 50 Not in file 51 Not in file on CMS batch system 52 Master record housed at another HOST site 53 Not in file in CMS but sent to CMS s alpha reinstate 55 Does not match a master record ER Consistency edit reject UR Utilization edit CR A B crossover edit Cl CICS processing problem SV Security violation Palmetto GBA Page 125 September 2015 Section 8 Health Insurance Query DDE User s Manual Field Name Description
5. Screen 3 MAP175A description of this screen is provided following Figure 8 MAP175A JM MAC SC HHH UAT 11001 NOT IN FILE CLAIM NAME DOB SEX INTER PROV PROV IND APP DT REASON CD DATE TIME REQ ID DISP CD TYPE DATE TRANSFER INITIATED TO CMS DATE CMS INDICATED NIF AT OTHER SITE PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE Figure 8 Beneficiary CWF Screen 3 Field Name Description CLAIM The beneficiary s Health Insurance Claim Number HICN as shown on the Medicare card NAME Beneficiary s first initial and last name DOB Beneficiary s date of birth SEX Beneficiary s Sex Valid values are F Female M Male INTER The provider s Medicare Contractor number PROV The Provider s Medicare billing number This is a six digit number PROV IND This field identifies the provider number indicator Valid values are The provider number is a Legacy or OSCAR number N The provider number is an NPI number APP DT This field is used for spell determination such as the admission date and current date MMDDYY format REASON CD This field identifies the reason for the inquiry Valid values are 1 Status inquiry 2 Inquiry related to an admission DATE TIME This field identifies the date and time the request was made Julian date format REQ ID Requester ID This field identifies the individual who submitted the inquiry
6. eeeeeeeeeeeneeeeeenen 159 Figure 94 CWF Part A Inquiry Reply Screen Page 12 eese nennen 160 Figure 95 CWF Part A Inquiry Reply Screen Page 13 sess 161 Figure 96 CWF Part A Inquiry Reply Screen Page 14 seen 162 Figure 97 CWF Part A Inquiry Reply Screen Page 15 oie eesceseceseceseceseeeseeeseeeeeeeeneeeaeeeaeeeaeeenaes 163 Figure 98 CWF Part A Inquiry Reply Screen Page 16 164 This publication was current at the time it was published Medicare policy may change so links to the source documents have been provided within the document for your reference This publication was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services The Centers for Medicare amp Medicaid Services CMS employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide This publication is a general summary that explains certain aspects of the Medicare Program but is not a legal document The official Medicare Program provisions are con
7. Palmetto GBA Page 14 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description DISP CD CWF Disposition Code This field identifies a code assigned when the request is processed through the CWF host site TYPE This field identifies the type of reply from CWF Valid value is 4 Not in File DATE TRANSFER This field identifies the first date the transfer was initiated to CMS INITIATED TO CMS DATE CMS This field identifies the date CMS indicated the beneficiary HIC was not in file at INDICATED another site MMDD YY format NIF AT OTHER SITE Screen 4 MAP175J Field descriptions are provided in the table following Figure 9 MAP175J JM MAC VA WV UAT 11003 SC ACCEPTED HIC NM IT DB SX PRVN SERVC TECH D PROF D PRVN SERVC TECH D PROF D PRVN SERVC TECH D PROF D CARD 80061 DIAB 82951 PAPT G0147 CARD 82465 PCBE G0101 PAPT G0148 CARD 83718 PPV 90732 AAA G0389 CARD 84478 PPV 90669 PTWR G9143 C0LO G0104 PROS G0102 IPPE G0402 COLO G0105 PROS G0103 IPPE G0403 COLO G0106 PAPT Q0091 IPPE G0404 COLO G0120 GLAU G0117 IPPE G0405 COLO G0121 GLAU G0118 PULM G0424 FOBT G0107 MAMM G0202 CR FOBT G0328 MAMM G0203 ICR FOBT 82270 MAMM 76092 AWV G0438 IPPE G0344 MAMM 77057 AWV G0439 IPPE G0366 PAPT P3000 PPV 90670 IPPE G0367 PAPT G0123 HIBC G0445 IPPE G0368 PAPT G0143 BEHV G0447 DIAB 82947 PAPT G0144 DIAB 82950 PAPT G0145 PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF6 S
8. ASC GRP Identifies the Ambulatory Surgical Center Group code for the indicated revenue code ASC Identifies the Ambulatory Surgical Center Percentage used by the ASC Pricer in its calculation for the indicated revenue code CONTR This field identifies the contractor amounts UB 04 CLAIM ENTRY PAGE 2 ADDITIONAL DETAIL This page is a copy of core claim MAP171D Providers may only view this page No additions modifications or deletions may be made here This page is accessed by pressing F2 or F11 three times on claim page 2 MAP1712 Palmetto GBA Page 80 September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Screen Page 2 Additional Details MAP171D Field descriptions for this screen are provided in the table following Figure 44 MAP171D PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY DCN HIC RECEIPT DATE STATUS LOCATION TRAN DT STMT COV DT PROVIDER ID BENE NAME NONPAY CD GENER HARDCPY MR INCLD IN COMP CL MR IND TPE TO TPE USER ACT CODE WAIV IND MR REV URC DEMAND REJ CD MR HOSP RED RCN IND MR HOSP RO ORIG UAC MED REV RSNS OCE MED REV RSNS HCPC MOD IN SERV REASON CODES REV HCPC MODIFIERS DATE COV UNT COV CHRG ADR FMR ORIG ORIG REV MR ODC OCE OVR CWF OVR NCD OVR NCD DOC NCD RESP NCD NON NON DENIAL OVER ST LC MED ANSI LUAC COV UNT COV CHRG REAS CODE OVER TEC ADJ GRP REMARKS TOTAL LINE ITEM REASON CODES PROCESS COMPLETED
9. MSG Message The verbiage pertaining to the disposition code CORRECT Correct Claim Number Displays the beneficiary s correct HIC number If the HIC entered in the inquiry screen Figure 66 is different than the number in this field this is the number you will use to submit claims NM Corrected Name This field displays the beneficiary s correct name The name in this field will be different only if the name entered in the inquiry Figure 66 screen is not consistent with CMS s record IT Corrected Initial This field displays the beneficiary s correct initial of the first name The initial in this field will be different only if the initial entered in the inquiry screen Figure 66 is not consistent with CMS s record DB Corrected Date of Birth This field displays the beneficiary s correct date of birth The date of birth in this field will be different only if the date of birth entered in the inquiry screen Figure 66 is not consistent with CMS s record SX Corrected Sex Codes This field displays the beneficiary s correct sex The sex code in this field will be different only if the sex code entered in the inquiry screen Figure 66 is not consistent with CMS s record A ENT Part A Entitlement Date of entitlement to Part A benefits in a MMDDYY format A TRM Part A Termination Indicates date of termination of Part A entitlement when applicable in a MMDDYY format Otherwise this field will display all zeros B EN
10. T UB 04 PIGA Field Name X Ref Description REV CD PAGE This field identifies the page number for the revenue code lines A total of 01 13 revenue code lines can be entered on each page F6 to move to the next revenue code line page The page number will change as you move through the revenue code pages HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system The default S LOC is S B0100 PROVIDER 57 This field displays the provider identification number UTN Unique Tracking Number UTN This is a 14 digit field that identifies the UTN submitted on the claim in the Medicare Treatment Authorization field The UTN is submitted on claims that require prior authorization See figure 47 regarding the Treatment Authorization field PROG Program Indicator This field identifies the Prior Authorization Program ID matching to the item services submitted on the claim This is a four digit alpha numeric field The valid format is ANNN or HNNN CL Identifies the claim line number of the Revenue Code There are 13 revenue code lines per page with a total of 450 revenue code lines possible per cla
11. Figure 96 CWF PartA Inquiry Reply Screen Page 14 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA ALCOHOL This field identifies the HCPCS code billed for Alcohol abuse screening ABUSE ALCOHOL This field identifies the HCPCS code billed for a face to face behavioral counseling SCREENING for alcohol misuse ADULT This field identifies the HCPCS code billed for the annual depression screening DEPRESSION IBT FOR CVD This field identifies the HCPCS code billed for Intensive Behavioral Therapy IBT OBESITY for Covered CVD Obesity NEXT ELIG Next Eligible Technical Date This field identifies the next date the patient is TECH eligible for the technical component of the screening NEXT ELIG Next Eligible Professional Date This field identifies the next date the patient is PROF eligible for the professional component of the screening Palmetto GBA Page 162 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 14 Field definitions and completion requirements are provided in the table following Fi
12. Calculates a per diem payment based on the standard DRG payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will not calculate the cost outlier portion of the payment TOTAL CHARGES The total covered charges submitted on the claim DOB The beneficiary s date of birth MMDDYYYY format OR AGE The beneficiary s age at the time of discharge This field may be used instead of the date of birth and century indicator APPROVED LOS The approved length of stay LOS is necessary for the Pricer to determine whether day outlier status is applicable in non transfer cases and in transfer cases to determine the number of days for which to pay the per diem rate Normally Pricer covered days and approved length of stay will be the same However when benefits are exhausted or when entitlement begins during the stay Pricer length of stay days may exceed Pricer covered days in the non outlier portion of the stay COV DAYS The number of Medicare Part A days covered for this claim Pricer uses the relationship between the covered days and the day outlier trim point of the assigned DRG to calculate the rate Where the covered days are more than the approved length of stay Pricer may not return the correct utilization days The CWEF host system determines and or validates the correct utilization days to ch
13. KEY The provider number PAGE The specific page you are viewing within the report SEARCH Allows searching for a particular type of claim or summary count information Cycles through Inpatient Outpatient Lab Other category REPORT The unique number assigned to the Summary of Pending Claims Other report CYCLE DATE Identifies the production cycle date in MMDDYY format TITLE OF The right side of the Scroll Left screen shows the title of the report This field is not REPORT labeled but the Report title changes as the user cycles through the available Type of Bills e g Pending Processed or Returned BLUE CROSS The BCBS identification number assigned to a particular provider facility CODE TYPE OF CLAIM The field is not titled but the type of claim can be found under the report title on the right side of the Scroll Left screen This field identifies the type of claim being reflected on the report e g Inpatient Outpatient Lab Other NAME The Beneficiary s Last Name First Name MED REC The unique number assigned to the beneficiary at the medical facility NUMBER HIC NUMBER Identifies the unique Health Insurance Claim Number assigned to the beneficiary as shown on the Medicare card This number is to be used on all correspondence and to facilitate the payment of claims RECD DATE The date on which the Medicare contractor received the claim from the provider in MMDDYY format ADMIT DATE The date the patient was admitted to
14. Rep Payee Indicator 0 Does not apply 1 Selected for GEP Contract 2 Has Rep Payee 3 Both Conditions Apply Pos 7 10 Not used at this Pre filled with zeros time NAME Displays last name first name and middle initial of the beneficiary patient ZIP Zip Code of the residence of the beneficiary Palmetto GBA Page 20 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description PLAN ENR CD Number of periods of Plan enrollment code Valid values include 0 Zero periods of enrollment 1 One period of enrollment 2 Two periods of enrollment 3 More than two periods of enrollment Current Plan CUR ID Current Plan ID code assigned by CMS Position Description 1 H or 1 9 2 amp 3 State code 4 amp 5 Plan number within the state OPT Plan Option Code Valid values are Restricted A Medicare contractor to process all claims B Plan to process claims for directly provided services C Plan to process all claims Unrestricted 1 Medicare contractor to process all Part A and Part B provider claims 2 Plan to process claims for directly provided services from providers with effective arrangements ENR The enrollment date of the Plan benefits in MMDDYY format TERM DT The termination date of the Plan benefits in MMDDYY format Prior Plan PRI ID Prior Health ID code assigned by CMS Position Description 1 H or 1 9 2 amp 3 State code 4 amp 5 Plan number wi
15. LABOR Identifies the labor amount of the payment as calculated by the pricer NON LABOR Identifies the non labor amount of the payment as calculated by the pricer MED This is the total Medicare Reimbursement for the line item It will be the sum of the Patient Reimbursement and the Provider Reimbursement ADJUSTMENT The following calculation will be performed to obtain the total Contractual Adjustment Submitted Charges Deductible Wage Adjusted Coinsurance Blood Deductible Value Code 71 Psychiatric Reduction Value Code 05 Other Reimbursement Amount For MSP claims the MSP deductible MSP blood deductible and MSP coinsurance are used in the above calculation in place of the deductible blood deductible and coinsurance amounts Not displayed on new claims MSP claims cannot be submitted or corrected in DDE ANSI The ANSI Group ANSI Adjustment Code consists of a 2 character group code and a 3 character reason adjustment code It is used to send ANSI information to the Financial System for reporting on the remittance advice PRICER AMT The Pricer Amount provides the line item reimbursement received from a Pricer PRICER RTC Identifies the Pricer Return Code from OPPS Valid values include Describes how the bill was priced 00 Priced standard DRG payment 01 Paid as day outlier send to PRO for post payment review 02 Paid as cost outlier send to PRO for post payment review 03 Paid
16. SRV SRV PERIOD OWNER CHANGE ST DT 2ND OWNER CHANGE ST DT 1ST Palmetto GBA September 2015 SC MAMMO DT PART B DATA MEDICAL EXPENSE BLD DED BLD DED REM CSH DED YR PSY EXP YR PLAN DATA EFF DT EFF DT EFF DT CANC DT CANC DT CANC DT HOSPICE DATA PROVIDER PROVIDER PROVIDER INTER PROVIDER LST BILL DT INTER INTER TERM DT INTER DAYS BILLED 1ST DT ST DT BILL DT PLEASE CONTINUE PF8 CWF INQUIRY PROCESS COMPLETED PRESS PF3 EXIT PF7 PREV PAGE Figure 7 Beneficiary CWF Screen 2 Section 4 Claim Inquiry DDE User s Manual Field Name Description RI In DDE CWF this Reason for Inquiry field is hard coded with a 1 needed for HIQA Inquiry Valid values are 1 Inquiry 2 Admission Inquiry MAMMO DT Mammography Date Part B Data SRV YR The calendar year for current Medicare part B services that are associated with the cash deductible amount entered in the Medical Expense field MEDICAL EXPENSE The cash deductible amount satisfied by the beneficiary for the service year BLD DED REM The remaining of pints of blood to be met PSY EXP The dollar amount associated with psychiatric services SRV YR The calendar year for current Medicare Part B services that are associated with the cash deductible amount entered in the Medical Expense field and with the Blood Deductible field BLD DED This field is no longer applicable CSH DED This field is no longer ap
17. SUB TAXO CD TO DAYS COV N C co LTR FIRST MI DOB 2 4 CARR 6 LOC SEX MS ADMIT DATE HR TYPE SRC D HM COND CODES 01 02 03 04 05 06 07 08 OCC CDS DATE 01 02 06 07 SPAN CODES DATES 01 05 09 FAC ZIP VALUE CODES AMOUNTS MSP APP IND PLEASE ENTER DATA PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF7 PREV PF8 NEXT Figure 40 UB 04 Claim Entry Screen Page 1 NOTE The SC field will display at the top of each claim page This field can be used to navigate to any of the claim inquiry screens if desired during the claim entry process Ex Enter 17 to navigate directly to the reason code inquiry screen To navigate back to the claim page press F3 Field Name eg Description HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system OSCAR 57 Displays the identification number of the institution that rendered services to the beneficiary patient The system will automatically pre fill the Medicare Oscar number when logging on to the DDE system If your facility has sub units SNF ESRD CORF ORF the Medicare Oscar number must be changed to reflect the provider you wish t
18. 2 transmission S B90 2 additional transmissions CWF Host Sites The Centers for Medicare amp Medicaid Services maintains centralized files on each Medicare beneficiary with minimal eligibility and utilization data Contractors query this file to process claims CWF disperses the beneficiary files into nine regional host sites GL Great Lakes MA Mid Atlantic SE Southeast GW Great Western Illinois Indiana Alabama Idaho North Dakota Michigan Maryland Mississippi lowa Oregon Minnesota Ohio North Carolina Kansas South Dakota Wisconsin Virginia South Carolina Missouri Utah West Virginia Tennessee Montana Washington Nebraska Wyoming PA Pacific SO South KS Keystone NE Northeast SW Southwest Alaska Florida Delaware Connecticut Arkansas Arizona Georgia New Jersey Maine Colorado California New York Massachusetts Louisiana Hawaii Pennsylvania New Hampshire New Mexico Nevada Rhode Island Oklahoma Vermont Texas HIQH Inquiry Screen Once you have successfully logged onto the HIQH function the CWF beneficiary inquiry area will display Figure 82 To access a beneficiary s CWF Master Record enter information into this screen HIQH Inquiry Screen Field definitions and completion requirements are provided in the table following Figure 82 CWF PART A INQUIRY Figure 82 CWF Part A Beneficiary Inquiry Screen Palmetto GBA Page 146 September 2015 Section 9 Health Insurance Query for HHAs
19. Field Name RESPONSE CODE DDE User s Manual Description Data in this field a C for Display on CRT is automatically inserted by the system CLAIM NUMBER Enter the beneficiary s Medicare number as shown on the Medicare card in this field REQUESTOR ID SURNAME Enter the first six 6 letters of the beneficiary s last name INITIAL Enter the first initial of the beneficiary s first name DATE OF BIRTH Enter the beneficiary s date of birth in MMDDCCYY format SEX CODE Enter the beneficiary s sex Valid values are F Female M Male Identifies person submitting the inquiry or person requesting printed output Enter 1 in this field PRINTER DEST Leave this field blank system default printer This field is for the Printer device that the response will be directed to if a P or E is typed in the Response Code field INTER NO Identifies the Medicare contractor processing the claim Enter one of the following for a beneficiary in Palmetto GBA s jurisdiction 11201 Part A South Carolina 11501 Part A North Carolina 11301 Part A Virginia 11401 Part A West Virginia 11004 Home health or hospice PROVIDER NO The six digit number assigned by Medicare to the provider rendering medical service to the beneficiary HOST ID Host IDs are shown as two letter abbreviations for the nine CWF host sites You should access the appropriate host and enter one of the foll
20. PLEASE CONTINUE PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF10 LEFT Figure 44 UB 04 Claim Entry Page 2 Additional Detail UB 04 X Ref DCN The document control number assigned to the claim HIC 60 The patient s Medicare number as shown on the Medicare card Field Name Description RECEIPT The date the claim was received into the Medicare claims processing DATE system Not required for new claims entry TOB 4 This field shows the type of bill being submitted STATUS The current status of the claim New claim entries will display S LOCATION The current location of the claim in the system New claim entries will display B0100 until F9 is pressed TRAN DT This field displays the transaction date Not displayed on new claim entries STMT COV 6 The statement cover dates entered on MAP1711 DT TO PROVIDER ID 57 Identifies the identification number of the Provider submitting the claim BENE NAME 8a The name of the Beneficiary 20 positions for the last name and 10 positions for the first name NON PAY CD The Non Pay Code identifies the reason for Medicare s decision not to make payment Valid values include Benefits exhausted Non Covered Care discontinued First Claim Development Contractor 11107 Trauma Code Development Contractor 11108 Secondary Claims Investigation Contractor 11109 Self Reports Contractor 11110 411 25 Contractor 11111 Insurer
21. PTB Beneficiary is not entitled to Part B RCVD Beneficiary already received service DOD Beneficiary not eligible due to date of death GDR Beneficiary not eligible due to gender AGE Beneficiary not eligible due to age SRV Beneficiary not eligible for the service VAC Beneficiary already vaccinated Service not applicable Screen 5 MAP175M Field descriptions are provided in the table following Figure 10 MAP175M JM MAC VA WV UAT 11003 Sc ACCEPTED HIC NM IT DB SX PRVN SERVC TECH D PROF D PRVN SERVC TECH D PROF D PRVN SERVC TECH D PROF D TELH 99231 BONE 77085 TELH 99232 TELH 99233 TELH 99307 TELH 99308 TELH 99309 TELH 99310 BEHV G0442 BEHV G0443 BEHV G0444 BEHV G0446 BONE 77078 BONE 77080 BONE 77081 BONE 76977 BONE G0130 BEHV G0473 HCAS G0472 PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF5 SCROLL BKWD PF7 PREV PAGE PF8 NEXT PAGE Figure 10 Beneficiary CWF Screen 5 Field Name Description HIC The beneficiary s Medicare number as it appears on the Medicare ID card NM The beneficiary s last name IT The initial of the beneficiary s first name DB The beneficiary s date of birth in MMDDYY format SX The beneficiary s sex Valid values are F Female M Male PRVN SRVC This field identifies the preventative service category Palmetto GBA Page 16 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description TECH D Tec
22. SECTION 6 CLAIM CORRECTION The Claim and Attachments Correction Menu displays Figure 51 when 03 is chosen from the Main Menu The detailed explanations for the claim page screens are provided in Section five 5 of this manual Claim and Attachments Correction Menu Screen MAP1704 MAP1704 JM MAC NC UAT PALMETTO GBA 11501 CLAIM AND ATTACHMENTS CORRECTION MENU CLAIMS CORRECTION INPATIENT 21 OUTPATIENT 23 SNF 25 HOME HEALTH 27 HOSPICE 29 CLAIM ADJUSTMENTS CANCELS INPATIENT 30 50 OUTPATIENT 31 51 SNF 32 52 HOME HEALTH 33 53 HOSPICE 35 55 ATTACHMENTS PACEMAKER 42 AMBULANCE 43 THERAPY 44 HOME HEALTH 45 ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 51 Claim and Attachments Correction Menu Claim correction allows you to Correct Return To Provider RTP claims Suppress RTP claims that you do not wish to correct Adjust claims Cancel claims Note The system will automatically enter your provider number into the PROVIDER field If the facility has multiple provider numbers the user will need to change the provider number to inquire or input information TAB to the PROVIDER field and type in the correct provider number Online Claims Correction If a claim receives an edit FISS reason code a Return to Provider RTP is issued An RTP is generated after the transmission of the claim The claim is returned for correction Until the claim is corrected via DDE or hardcopy it
23. UPIN first and last name Palmetto GBA Page 88 September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Screen Page 3 MAP1713 Field descriptions are provided in the table following Figure 45 MAP1713 PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY HIC S LOC PROVIDER NDC CODE OFFSITE ZIPCD CD ID PAYER RI AB EST AMT DUE DUE FROM PATIENT SERV FAC NPI MEDICAL RECORD NBR COST RPT DAYS NON COST RPT DAYS DIAG CODES 01 02 03 04 05 06 07 08 09 END OF POA IND ADMITTING DIAGNOSIS HOSPICE TERM ILL IND IDE GAF PRV PROCEDURE CODES AND DATES 01 02 03 04 05 06 ESRD HOURS ADJUSTMENT REASON CODE REJECT CODE NONPAY CODE ATT PHYS NPI L OPR PHYS NPI L OTH OPR NPI L REN PHYS NPI L REF PHYS NPI L PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF7 PREV PF8 NEXT PF9 UPDT Figure 45 UB 04 Claim Entry Page 3 UB 04 Field Name X Ref Description HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system PROVIDER 57 This field displays the provider identification number NDC CODE This field identifies the National Drug Code
24. ancillary service or billing calculation EFF DT Date the code became effective active IND The effective date indicator instructs the system to either use the from date on the claim or the System Run Date to perform edits for this revenue code Valid codes are F From date R Receipt date D Discharge date TERM DT Date the code was terminated no longer active NARR English language description of the code TOB Identifies all Type of Bill codes within the Medicare Part A system that are allowed by Medicare Palmetto GBA Page 45 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description ALLOW EFF DT Identifies whether the revenue code is currently valid for a specific Type of Bill TRMDT Valid values are Y Yes N No HCPC EFF DT Identifies whether a Healthcare Common Procedure Code HCPC is required TRM DT from specific types of providers for this Revenue Code by Type of Bill Valid values are Y HCPC required for all providers N HCPC not required V Validation of HCPC is required F HCPC required only for claims from free standing ESRD facility H HCPC required only for claims from hospital based ESRD facility UNITS EFF DT Identifies if the revenue code requires units to be present for a specific Type of TRM DT Bill Valid values are Y Yes N No RATE EFF DT Identifies if the revenue codes require a rate to be present for a specific Ty
25. 83X HOSP ESRD Reflects all Hospital End Stage Renal Disease claims with a Type of Bill 72X LCF ESRD Reflects all claims with a Long Term Care Facility End Stage Renal Disease Type of Bill 72X and a provider number greater than XX299 and less than XX2500 XX represents the state code H C Claims by bill type which are produced on paper and submitted to the Medicare contractor designated by a Uniform Bill Code less than 8 AUTO Claims by bill type which are submitted to the Medicare contractor in an electronic mode designated by a Uniform Bill Code greater than 7 Right Scroll View CORF Reflects all CORF claims adjustments with a Type of Bill 75X HOSPICE Reflects all Hospice claims adjustments with a Type of Bill 81X or 82X ANC OTHER Reflects all Ancillary and Other claims with a Type of Bill 12X 14X 22X 24X 42X 44X 52X 54X 71X 74X or 79X TOTAL The total of all claims printed on this report for each specific Reason Code H C Claims by bill type which are produced on paper and submitted to the Medicare contractor designated by a Uniform Bill Code less than 8 AUTO Claims by bill type which are submitted to the Medicare contractor in an electronic mode designated by a Uniform Bill Code greater than 7 Palmetto GBA Page 121 September 2015 Section 8 Health Insurance Query DDE User s Manual SECTION 8 HEALTH INSURANCE QUERY ACCESS The Health Insurance Query Access HIQA
26. CLAIMS MED B E1 ESRD ATTACH ANSI CODES GROUP ADJ REASONS APPEALS PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF7 PREV PF8 NEXT PF9 UPDT Figure 46 UB 04 Claim Entry Page 4 UB 04 Field Name X Ref Description REMARK There are a total 3 pages to enter remarks Press F6 to advance to the PAGE 01 next page The page number will change each time you press F6 HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system PROVIDER 57 This field displays the provider identification number REMARKS 80 Maximum of 711 positions characters can be entered Enter any remarks needed to provide information not reported elsewhere on the bill but which may be necessary to ensure proper Medicare payment This field carries the remarks information as submitted on automated claims as well as provides internal staff with a mechanism to provide permanent comments regarding special considerations that played a part in adjudicating the claim e g the Medical Review Department may use this area to document their rationale for the final medical determination or t
27. Control file Valid values are 1 9 REASON To view a specific adjustment reason code enter the value in this field To view all CODE adjustment reason codes press ENTER in this field There are hard coded and user defined codes PRO Review Code letters are indicated in brackets S Selection Used to view information for a particular code To select an adjustment reason code tab to desired code enter S in the selection field and press ENTER PC The Plan Code differentiates between plans Intermediaries that share a processing site The home or host site is considered 1 by the system It is the number assigned to the site on the System Control file Valid values are 1 9 RC Displays the adjustment reason code To review a particular adjustment reason code enter the adjustment reason code value in this field HC HIGLAS Adjustment Reason Code This field identifies the Healthcare Integrated Ledger Accounting System HIGLAS adjustment reason code This is a two position alphanumeric field NOTE This field only displays on NON HIGLAS sites TYPE Displays the type of claim type associated with this reason code when a valid adjustment reason code is entered Valid values are Inpatient SNF O Outpatient H Home Health CORF A All Claims NARRATIVE The narrative provides a short description for the adjustment reason code Palmetto GBA Page 51 September 2015 Section 4 Claim Inqu
28. DDE User s Manual Field Name Description Home Health Certification REQ DATE Date the request was made through DDE HIC The beneficiary s Medicare number as shown on the Medicare card DOB The beneficiary s date of birth in MMDDYY format NAME The beneficiary s last and first name REC This field identifies the health insurance record number HCPCS This field identifies the HCPCS code billed FROM DATE This field identifies the home health from date in MMDDYY format DRG Pricer Grouper Select option 11 from the Inquiry Menu to access the DRG PPS Inquiry screen MAP1781 amp MAP178B The DRG PPS Inquiry screen displays detailed payment information calculated by the Pricer and Grouper software programs Its purpose is to provide specific DRG assignment and PPS payment calculations It should be used to research PPS information as it pertains to an inpatient stay To start the inquiry process enter the following information Diagnosis code Date of Discharge Approved length of stay Procedure code Provider number LOS Sex Review code Covered days Century indicator Total charges Number of lifetime reserve Discharge status Date of birth or age days TAB to move between fields on the screen Only press ENTER when all fields have been completed DRG PPS Inquiry Screen DRG PPS Screen MAP1781 Field Descriptors are in the table that follows Figure 18 JM MAC VA WV
29. Discounting Factor Flag 4 Line Item Denial or Rejection Flag 5 Packing Flag 6 Payment Adjustment Flag 7 Type of Bill Inclusion Flag8 Line Item Action MSP This field identifies the MSP Payer 1 and Payer 2 amounts entered based on the value codes entered Not required on new claims entry Not displayed on new claims MSP claims cannot be submitted through DDE ID This Medicare Secondary Payer Payer 1 ID code identifies the specific payer If Medicare is primary this field will be blank or populated with a Z for Medicare Valid values are Medicaid Blue Cross Other None Working Aged End Stage Renal Disease ESRD Beneficiary in 12 month coordination period with an employer group health plan Conditional Payment Auto No Fault Workers Compensation Public Health Service or other Federal Agency Disabled Black Lung Veterans Administration Liability REIMB The Patient Reimbursement amount is determined by the system to be paid to the patient on the basis of the amount entered by the Provider on claim page 3 in the Due from Pat field This amount is the calculated line item amount RESP Patient Responsibility identifies the amount for which the individual receiving services is responsible The amount is calculated as follows e f the Payer 1 indicator is C or Z then the amount will equal Cash Deductible Coinsurance Blood Deductible e f the Payer 1 ind
30. Diseases and Disorders of the Kidney and Urinary Tract 12 Diseases and Disorders of the Male Reproductive System 13 Diseases and Disorders of the Female Reproductive System 14 Pregnancy Childbirth and the Puerperium 15 Newborns and Other Neonates with Conditions Originating in the Prenatal Period 16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description 17 Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms 18 Infectious and Parasitic Diseases Systemic or Unspecified Sites 19 Mental Diseases and Disorders 20 Alcohol Drug Use and Alcohol Drug Induced Organic Mental Disorders 21 Injuries Poisonings and Toxic Effects of Drugs 22 Burns 23 Factors Influencing Health Status and Other Contacts with Health Services 24 Multiple Significant Trauma 25 Human Immunodeficiency Viral Infections RETURN CODE The Return Code reflects the status of the claim when it has returned from the Grouper Program This is a one digit alphanumeric field PROC CD USED Procedure code s that identify the principal procedure s performed during the billing period covered by the claim Required for inpatient claims DIAG CD USED Identifies the primary diagnosis code used by the Grouper program for calculation SEC DIAG USED Diagnos
31. Facility SSA Social Security Administration X Ref Cross reference SSI Supplementai Security Income is SLP Speech Language Pathology Y2K Year 2000 SMSA Standard Metropolitan Statistical Area Palmetto GBA Page 166 September 2015
32. G0121 07012001 07012001 GLAU G0117 G0118 01012002 FOB TEST G0107 04022002 04022002 MAMM G0202 G0203 04012001 FOB TEST G0328 01012004 01012004 MAMM 76092 01011998 FOB TEST 82270 01012007 01012007 MAMM 77057 01012007 IPP EXAM G0344 SRVNOELG SRVNOELG PAPT P3000 G0123 07012001 07012001 IPP EXAM G0366 SRVNOELG SRVNOELG G0143 G0144 IPP EXAM G0367 SRVNOELG 00000000 G0145 G0147 IPP EXAM G0368 00000000 SRVNOELG G0148 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 88 CWF Part A Inquiry Reply Screen Page 6 HIQHCRO CWF HOME HEALTH INQUIRY REPLY PAGE 07 OF 16 IP REC CN NM IT DB INT 11004 PREVENTIVE SERVICE TECH DTE PROF DTE MMDDCCYY MMDDCCYY AAA G0389 07012007 07012007 IPP EXAM G0402 SRVNOELG SRVNOELG PREVENTIVE SERVICE TECH DTE PROF DTE MMDDCCYY MMDDCCYY IPP EXAM G0403 SRVNOELG SRVNOELG IPP EXAM G0404 SRVNOELG 00000000 IPP EXAM G0405 00000000 SRVNOELG PTWR G9143 08032009 08032009 AWV G0438 00000000 01012011 AWV G0439 00000000 01012011 HCAS G0472 06022014 06022014 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 89 CWF Part A Inquiry Reply Screen Page 7 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date o
33. Hospice claim DOEBA Date of earliest billing action DOLBA Date of last billing action DAYS USED Lists the number of days used per benefit period START DATE Lists second start date if a beneficiary elects to change hospices during a benefit period PROV2 Indicates the Second provider number to submit hospice claims when a beneficiary chooses to change providers during a benefit period INTER2 Second Intermediary Number Indicator as to the Medicare contractor that is processing the hospice claim if the beneficiary elects to change hospices during a benefit period that submits claims to a different contractor REVOCATION Revocation Indicator Indicates if a beneficiary has revoked hospice benefits for IND the period Valid values are 0 Beneficiary has not revoked hospice benefits 1 Beneficiary has revoked hospice benefits 2 Beneficiary has revoked hospice benefits record was manually updated by CWF at the request of the Medicare contractor Palmetto GBA Page 158 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 11 Field definitions and completion requirements are provided in the table following Figure 93 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 93 CWF PartA Inquiry Reply Screen Page 11 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of th
34. NDC OFFSITE ZIPCD This field identifies offsite Clinic Outpatient department zip codes It determines the claim line HPSA PSA bonus eligibility NOTE When a zip code is present the system uses the zip code for processing not the zip code for the base provider CAH Indicating that one of the off site clinics outpatient departments submitted the claim for payment and not the base provider CAH CD 50 A Use the following list of Primary Payer Codes when submitting electronic B C claims for payer identification The following codes are for Medicare requirements only Other payers require codes not reflected Not displayed on new claims MSP claims cannot be submitted or corrected in DDE Valid values are Medicaid Blue Cross Other None Working age Employer Group Health Plan EGHP End Stage Renal Disease ESRD beneficiary in 30 month coordinated period with an Employer Group Health Plan Conditional payment O DWrRONDH Palmetto GBA Page 89 September 2015 Section 5 Claim Entry DDE User s Manual Field Name easy Description D Automobile no fault E Workers compensation F Public Health Service PHS or other federal agency G Disabled Large Group Health Plan LGHP H Black lung federal black lung program Veteran s administration L Liability Z Medicare A ID Not required PAYER 50 A Payer Identification lines B C A Primary Paye
35. NEXT Figure 74 CWF Part A Inquiry Reply Screen Page 9 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA COUNSELING Identifies up to five years of counseling data Valid values include PERIOD T one year 2 two years 3 three years 4 four years 5 five years TOTAL Identifies the number of sessions billed for the beneficiary SESSIONS HCPCS HCPCS Code FROM From date of claim THRU Through date of claim PER Identifies up to five years of counseling data Valid values include T one year 2 two years 3 three years 4 four years 5 five years QT Quantity The number of services billed for each date TP Claim type Palmetto GBA Page 136 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 10 Field descriptions for Page 10 of the HIQA screen are provided in the table following Figure 75 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 75 CWF PartA Inquiry Reply Screen Page 10 Field Name Description
36. Name DDE User s Manual Description DEDUCTIBLES The amount of Medicare Patient Blood Deductible applied to the line item BLOOD Blood deductible will be applied at the line level on revenue codes 380 381 and 382 DEDUCTIBLES The amount of Medicare patient cash deductible applied to the line item CASH This field is system filled COINSURANCE The amount of Patient Wage Adjustment Coinsurance applicable to the line WAGE ADJ based on the particular service rendered The revenue and HCPCS code submitted define the service For services subject to outpatient PPS OPPS in hospitals TOB 12X 13X and 14X and in community mental health centers TOB 76X the applicable coinsurance is wage adjusted Therefore this field will have either a zero for the services without applicable coinsurance or a regular coinsurance amount calculated on either charges or a fee schedule unless the service is subject to OPPS If the service is subject to OPPS the national coinsurance amount will be wage adjusted based on the MSA where the Provider is located or assigned as the result of a reclassification CMS supplies the national coinsurance amount to the Fls as well as the MSA by Provider This field is System filled COINSURANCE REDUCED For all services subject to OPPS TOB 12X 13X 14X and 76X the amount of Patient Reduced Coinsurance applicable to the line for a particular coinsurance amount Providers are only permitted to reduce
37. Name Description HH REC The requested Home Health record CN Displays the identification number for a claim If an adjustment or a RTP is being processed enter the DCN for the claim If this is a MSP claim leave field blank NM The last name of the beneficiary patient IT The first initial of the beneficiary patient name DB The date of birth of the beneficiary patient SX Sex of the beneficiary patient Valid values F Female M Male PAP RSK PAP Risk Indicator Valid values are Y Yes N No PAP DATE The date of the beneficiary s last PAP Smear MAMMO RSK The mammography risk indicator Valid values are Y Yes N No Mammo Dates TECHCOM Technical Component Date The date the technician interpreted the mammography screening Up to three dates may be displayed in MMYY format PROCOM Professional Component Date The date the mammography screening required an interpretation by a physician Up to three dates may be displayed in MMYY format HCPC CD The Healthcare Common Procedure Code HCPC code DT 1 This field identifies the date the HCPC code was returned from CWF CCYY MM DD format TECH CD The technical code DT2 This field identifies the date the TECH code was returned from CWF CCYY MM DD format RISK CD The risk code DT 3 This field identifies the date the RISK code was returned from CWF Palmetto GBA Page 23 September 2015 Section 4 Claim Inquiry DDE Us
38. PREV PF8 NEXT Figure 80 CWF Part A Inquiry Reply Screen Page 15 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA Bone Density Services HCPCS This field identifies the HCPCS codes billed for the bone density services NEXT ELIGIBLE This field reflects the next eligible date for the technical component of the bone TECH DATE density services NEXT ELIGIBLE This field reflects the next eligible date for the professional component of the bone PROF DATE density services RULE This field identifies the allowable HCPCS codes and how often for the bone density services Palmetto GBA Page 142 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 16 Field descriptions for Page 16 of the HIQA screen are provided in the table following Figure 81 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 81 CWF PartA Inquiry Reply Screen Page 16 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary
39. REASON Identifies contains up to 10 5 digit reason codes requesting specific information CODES from the provider on claims for which the ADS indicator is Y CWFD CWF The total charges of the CWF category Location code positions 2 amp 3 90 DELAYED Location code position 4 is B F J L or M SUSP The total charges of all suspended claims Status S which do not fall into any SUSPENSE of the other listed categories e g MED MSP CWFR CWFD CLAIMS COUNT The total number of claims pending not processed at the end of the processing cycle for this Provider TOTAL The total charges by suspense category for pending claims or adjustments at the CHARGES end of the processing cycle ADJUSTMENTS Identifies by suspense category the total number of adjustments pending not COUNT processed at the end of the processing cycle for this Provider TOTAL Identifies by suspense category the total charges for pending claims or CHARGES adjustments at the end of the processing cycle 316 Errors on Initial Bills The Errors on Initial Bills report Figures 63 and 64 lists by Provider errors received on new claims claims entered into the system for the present cycle The purpose of this report is to provide a monitoring mechanism for claims management and customer service to use in determining problem areas for Providers during their claim submission process Palmetto GBA
40. REATIO These fields identify the ratio target amount and federal amount used during TARGET DRG operating PPS transition periods BLEND RATIO These fields identify the ratio of the regional amount and national amount use REG NAT during the operating PPS transition periods to determine the operating federal rate TARGET This field identifies the Target amount the updated hospital specific rate AMOUNT NOTE This is used to determine Health Service Area HSA add on amounts for sole community and Medicare dependents hospitals WAGE AMOUNT This field identifies the national wage related rate It is used to determine the NATIONAL labor portion of the operating federal rate WAGE AMOUNT This field identifies the regional wage related amount REGIONAL NON WAGE This field identifies the national non wage related rate It is used to determine the AMOUNT labor portion of the operating federal rate NATIONAL Palmetto GBA Page 37 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description NON WAGE FED AMOUNT RATIO NON WAGE This field identifies the regional non wage related amount AMOUNT REGIONAL WAGE AMOUNT This field identifies the wage related amount WAGE INDEX This field identifies the wage index as supplied by CMS to be used for the state in which the services were provided to determine reimbursement rates for the services rendered This field identifies
41. SC ACCEPTED HOSPICE INFO FOR PERIODS 3 AND 4 PERIOD 1ST ST DATE OWNER CHANGE ST DATE 2ND ST DATE PROV OWNER CHANGE ST DATE 1ST BILLED DT DAYS BILLED PERIOD OWNER CHANGE ST DATE 2ND ST DATE OWNER CHANGE ST DATE 1ST BILLED DT DAYS BILLED PROCESS COMPLETED LAST BILLED DT REVO IND 1ST ST DATE INTER INTER TERM DATE INTER PROV LAST BILLED DT REVO IND PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE Figure 15 Beneficiary C WF Screen 10 Field Name Description HOSPICE INFO There are four occurrences of Hospice Information on two screens to provide for FOR PERIODS 1 the four most recent hospice periods AND 2 Period 1 or 3 PERIOD The Hospice Benefit Period Number Valid values are 1 First time a beneficiary uses hospice benefits 2 Second time a beneficiary uses hospice benefits 1ST START DATE The beneficiary s effective period with the Hospice Provider MMDDYY format PROV The hospice s Medicare provider number INTER The hospice s Medicare contractor number OWNER CHANGE The start date of a change of ownership for the first Provider within the election ST DATE period PROV The number of the Medicare hospice Provider INTER The Medicare contractor number 2ND START DATE The date the second benefit period began PROV The second hospice s Medicare provider number INTER The second hospice s Medicare Contractor number TERM
42. Section 5 Claim Entry DDE User s Manual Field Name Description METHOD The method of home dialysis selected by the beneficiary Valid values are 1 Method Beneficiary receives all supplies and equipment for home dialysis from an ESRD facility and the facility submits the claims for their services 2 Method Il Beneficiary deals directly with one supplier and is responsible for submitting their own claim 382 EFFECTIVE DATE Identifies the date the Beneficiarys ESRD Method Selection becomes effective on the HCFA 382 form FUNCTION Three valid functions include E Entry U Update Inquiry LN Last name of the beneficiary at the time the method selection occurred FN First name of the beneficiary MI Middle Initial of the beneficiary if applicable DOB Beneficiary s date of birth SEX Sex of the beneficiary PROV Enter the ESRD Provider number or the facility for which you are entering the ESRD attachment The Medicare Provider number will system fill with the Provider number you used to log onto the DDE system Therefore if you have sub units multiple ESRD facilities you will need to change the Provider number to reflect the ESRD facility for which the attachment information is being entered NPI This field identifies the provider National Provider Identifier number TAXO CD Taxonomy Code This field identifies a collection of unique alphanumeric codes The code set is
43. Sort OPON fu 5h meet te Ct m e n e e HE E TES ees 108 Claims and Attachments Corrections essent en rennen eren teen nenne 108 P vor USEMCMUS UP 108 Claim V01dS Cancels sos jects fies m 109 Valid Claim Change Condition Codes eese eene 110 SECTION 7 ONLINE REPORTS 111 050 Report Claims Returned to Provider eese rennen nennen nennen 114 201 Report Pended Processed and Returned Claims esee 116 316 Errors on Initial Bills iieri reiner erte er meet gp d c ee e ete a HET eee Ld eR REEL SR ao ende 119 SECTION 8 HEALTH INSURANCE QUERY ACCESS 122 Part A CWE Send Process inde Dire Ibero eri rece ede Du CER Die ea EE phas Ea eb Ee bebe 122 Part A Response PrOCESS sess cits cectsises senses ccvedsinticaveogscvenadsdiveusstecvevsnaasewsees da etd Lee edo D Ey E e eb eb dee Eee 122 CWE Host SLES Em 123 HIQA Inquiry SCPeen deren reet odin rtu oats asd eene dts ears ek iere re tidings ol Daun ese Da 123 SECTION 9 HEALTH INSURANCE QUERY FOR HHA 145 Part Ai CWE Send Process nr etie re b Cep bu it a io eei EI he eeu n eser eee eer da 145 Part A Response Process ee rera enm eon inen vd te rh vaca cede Pe de EUER Er Due so ro race ore pedes ee emp en Ene 145 CWE HOSE SIES iiiter erepti Pe open ep esa Deo reque ere ee I neve een penetret ug du EaR OE EEE a 146 HOH Inquiry AAIeC 2 M anscas 146 APPENDIX ACRONYMS 165 TABLE OF FIGURES Figur
44. The Document Control Number is not required when entering a new bill Applicable only on adjustments void cancel TOB nn7 and nn8 VALUE CODES 39 The Value Codes and related dollar amount s identify monetary data AMOUNTS 41 necessary for the processing of a claim Palmetto GBA Page 69 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name ANSI 01 09 Description ANSI is a 5 digit field made up of 2 digit Group Codes and 3 digit Reason Adjustment Code This field is system filled and will be used for sending ANSI information for the value codes to the Financial System for reporting on the remittance advice Refer to your UB 04 Manual for valid values MSP APP IND This field identifies to the MSP PAY module whether the system apportions the primary payer s amount and the OTAF amounts if present Valid values are Apportion N Do not apportion X Ref a d This field is not required on claim entry MSP claims cannot be submitted through DDE UB 04 CLAIM ENTRY PAGE 2 Enter the following information on page two of the UB 04 Claim Entry screen Revenue codes the system will automatically submit the claim with the revenue codes in ascending order Dollar amounts without decimal points e g for 45 50 type 4550 Revenue code 001 should be used in the final revenue code entry and correspond with the totals for Total Charges Non covered Charges T
45. This is a one position alphanumeric field and the valid values are 0 through 9 HAC RED IND This field is reserved for future use This is a one position alphanumeric field The valid values for IPPS are Blank Hospital Acquired Condition Reduction Program Non PPS N Hospital Acquired Condition Reduction Program PPS HRR ADJ Hospital Readmission HPR Adjustment This field identifies the HRR adjustment This is a six digit field in 9 9999 format HER RED IND Electronic Health Record Adjustment Reduction Indicator This field identifies the HER adjustment reduction indicator for providers that are subject to claim adjustments when the provider does not meet the guidelines for use of EHR technology This is a one position alphanumeric field Valid values are Y Reduction applies Blank Reduction does not apply UNCOMP CARE Uncompensated Care Payment Amount This is the amount published by CMS AMT to the MACs by provider entitled to an uncompensated care payment amount add on The MACs enter the amount for each Federal Fiscal year begin date 10 01 based on published information This is a ten digit field in 9999999 99 format Claims Summary Inquiry Select option 12 from the Inquiry Menu to access the Claims Summary Inquiry screen MAP1741 The Claims Summary Inquiry screen displays specific claim history information for all pending RTP claims MSP claims Medical Review claims and proce
46. Through Date of the earliest processed bill IND The yearly data indicators Pos 1 0 Not Used 2 Clerical Involvement 3 Religious Non Medical Healthcare Institution SNF Usage 4 Both 1 and 2 Pos 2 0 Not Used 1 Through Date is Interim Pos 3 4 For Future Use INT The fiscal Medicare contractor number for earliest processed hospital bill with a deductible ADM The Admission Date for the earliest processed hospital bill with a deductible FRM The From Date for the earliest hospital bill processed with a deductible TO The Through Date for the earliest hospital bill processed with a deductible APP Deductible amount applied for the earliest hospital bill processed with a deductible ADJ IND The type of adjustment made Valid values are 0 No Adjustment 1 Downward Adjustment 2 Upward Adjustment CALC DED The amount of deductible calculated CMS DT The date the claim was processed by CMS Palmetto GBA Page 22 September 2015 Section 4 Claim Inquiry DDE User s Manual Screen 8 MAP1757 Field descriptions are provided in the table following Figure 13 MAP1757 JM MAC VA WV UAT 11003 SC ACCEPTED HH REC CN IT PAP RSK PAP DATE TECHCOM PROCOM MAMMO RSK MAMMO DATES HCPC CD TECH CD RISK CD TRANSPLANT INFO COV IND TRAN IND DIS DATE EPISODE EPISODE DOEBA START END PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 13 Beneficiary CWF Screen 8 Field
47. UAT 11003 SC DRG PPS INQUIRY DIAGNOSES 2 5 D POA 2 5 7 NPI SEX C I DISCHARGE STATUS DT PROV REVIEW CODE TOTAL CHARGES DOB OR AGE APPROVED LOS COV DAYS LTR DAYS PAT LIAB RETURNED FROM GROUPER GROUPER VERSION D R G MAJOR DIAG CAT RETURN CODE PROC CD USED DIAG CD USED SEC DIAG USED RETURNED FROM PRICER PRICER VERSION RTN CD WAGE INDEX OUTLIER DAYS AVG LENGTH OF STAY OUTLIER DAYS THRESHOLD OUTLIER COST THRES INDIRECT TEACHING ADJ TOTAL BLENDED PAYMENT HOSPITAL SPECIFIC PORTION FEDERAL SPECIFIC PORTION DISP SHARE HOSPITAL AMT PASS THRU PER DISCHARGE OUTLIER PORTION PTPD TEP STANDARD DAYS USED LTR DAYS USED PROV REIMB PROCEDURES 1 6 6 PLEASE ENTER DATA PFS EXIT PF6 FWD PF8 COST DISC PF11 RIGHT ENT PROC Figure 18 DRG PPS Inquiry Screen Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description DIAGNOSES Diagnosis Codes Seven character alphanumeric fields that identify up to nine 1 9 codes for coexisting conditions on a particular claim The admitting diagnosis is not entered PROCEDURES Procedure Codes Required for inpatient claims Seven digit field identifying the 1 9 principle procedure first and up to eight additional procedures POA This field identifies the last character of the Present on Admission POA indicator Valid values are Z The end of POA indicators for principal and if applicable other diagnos
48. When the item is not a partial hospitalization the HCPC APC code is displayed This data is read from the claims file If an APC is not found the value will default to 00000 Claim page 31 displays the HIPPS code if different from what is billed If medical changes the code the new HIPPS code is displayed in the PAY HCPC APC CD field and a value of M is in the OCE flag 1 field When a value of M is in the OCE flag 1 field the MR IND field is automatically populated with a Y If Pricer changes the code the new HHRG is displayed in the PAY HCPC APC CD field and a value of P is in the OCE flag 1 field If the HIPPS code was not changed fields PAY HCPC APC CD and OCE flag 1 are blank For Home Health PPS claims claim page 31 displays the HIPPS code if different from what is billed If the Inpatient Rehabilitation Facility IRF PPS Pricer returns a HIPPS CMG code different from what was billed the new HIPPS CMG code is displayed on the revenue code 0024 line in the PAY HCPC APC CD field and a value of I is displayed in the OCE FLAG 1 field If the IRF PPS Pricer does not change the HIPPS CMG code these fields are blank OUTLIER This field identifies the outlier amount paid if applicable PAYER 1 The amount entered by the user if available or apportioned by MSPPAY as payment from the primary Medicare Secondary Payer 1 payer The MSPPAY module based on amount in the value code for the primary payer apportions
49. a beneficiary becomes eligible for Medicare LAST NAME Enter the last name of the patient as it appears on the patient s Medicare Card or other Medicare notice FIRST NAME Enter the first name of the patient as it appears on the patient s Medicare Card or other Medicare notice INIT Enter the middle initial of the patient if applicable BIRTH DATE Enter the patient s date of birth in MMDDYYYY format SEX Enter the sex of the patient Valid values are M or F ADMIT DATE This field identifies the date of the patient s admission the system will auto fill this date when the roster is transmitted ADMIT TYPE This field identifies the code indicating the priority of admission The valid values are T Emergency 2 Urgent 3 Elective 4 Newborn 5 Trauma Center ADMIT DIAG This field identifies the diagnosis code describing the inpatient condition at the time of the admission when the roster is transmitted the system will auto fill the diagnosis code based on the type of vaccine that is being billed Palmetto GBA Page 99 September 2015 Section 5 Claim Entry DDE User s Manual Field Name Description PAT STATUS This field identifies the code indicating the patient s status at the ending service date in the period the system will auto fill the patient status when the roster is transmitted ADMIT SRCE This field identifies the way a patient was referred the system will auto fill this field when the
50. as per diem not potentially eligible for cost outlier 04 Standard DRG but covered days indicate day outlier but day or cost outlier status was ignored 05 Pay per diem days plus cost outlier for transfers with an approved cost outlier 06 Pay per diem days only for transfers without an approved outlier 10 Bad state code for SNF Rug Demo or Post Acute Transfer for Inpatient PPS Pricer DRG is 209 210 or 211 12 Post acute transfer with specific DRGs of 14 113 236 263 264 429 483 14 Paid normal DRG payment with per diem days or gt average length of stay 16 Paid as a Cost Outlier with per diem days or gt average length of stay 20 Bad revenue code for SNF Rug Demo or invalid HIPPS code for SNF PPS Pricer 30 Bad Metropolitan Statistical Area MSA Code Describes why the bill was not priced 50 No Provider specific information found 52 Invalid MSA in Provider file 53 Waiver State no calculated by PPS 54 DRG not 001 468 or 4717 910 55 Discharge date is earlier than Provider s PPS start date 56 Invalid length of stay 57 Review code not 00 07 58 Charges not numeric 59 Possible day outlier candidate Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name A Description 60 Review code 01 and length of stay indicates day outlier Bill is not eligible as cost outlier 61 Lifetime reserve days not numeri
51. average length of stay the standard payment is calculated It also calculates the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold 04 Pay average stay only Calculates the standard payment but does not test for days or cost outliers 05 Pay transfer with cost Pays transfer with cost outlier approved 06 Pay transfer no cost Calculates a per diem payment based on the standard payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will not calculate any cost outlier portion of the payment 07 Pay without cost Calculates the standard payment without cost portion 09 Pay transfer special DRG post acute transfers for DRGs 209 110 211 014 113 236 263 264 429 483 Calculates a per diem payment based on the standard DRG payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will calculate the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold 11 Pay transfer special DRG no cost post acute transfers for DRGs 209 110 Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description 211 014 113 236 263 264 429 483
52. benefit period was terminated OWNER CHANGE The start date of a change of ownership within the period for the second Provider ST DATE PROV The second hospice s Medicare provider number INTER The second hospice s Medicare Contractor number 1ST BILLED DT The date of each earliest hospice bill date in MMDDYY format LAST BILLED DT Each most recent hospice bill date in MMDDYY format DAYS BILLED Number of hospice dates used for each hospice period REVO IND The revocation indicator per hospice period Screen 11 MAPI175K Field descriptions are provided in the table following Figure 16 MAP175K JM MAC VA WV UAT 11003 SC SMOKING AND TOBACCO USE CESSATION COUNSELING SERVICES HICN LN FI DOB SEX COUNSELING PERIOD TOTAL SESSIONS HCPCS FROM THRU PER QT TP HCPCS FROM THRU PER QT TP PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 16 Beneficiary CWF Screen 11 Field Name Description Smoking and Tobacco Use Cessation Counseling Services HICN The beneficiary s Medicare number as it appears on the Medicare ID card LN The beneficiary s last name FI The first initial of the beneficiary s first name Palmetto GBA Page 26 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description DOB The beneficiary s date of birth in MMDDYY format SEX Valid values are F Female M Male COUNSELING This f
53. field identifies the LICENSED attending physician s identification number or Unique Physician Identification Number UPIN Code This is a six digit alphanumeric field NPI 76 This field identifies the NPI number L 76 This field identifies the last name of the attending physician F 76 This field identifies the first name of the attending physician M 76 This field identifies the middle initial of the attending physician SC This field identifies the attending physician s specialty code This information will automatically populate when the claim is submitted OPR PHYS 77 This field identifies the physician who performed the principal procedure Inpatient Part A Hospital Identifies the physician who performed the principal procedure If no principal procedure is performed leave blank Outpatient Hospital Identifies the physician who performed the principal procedure If there is no principal procedure the physician who performed the surgical procedure most closely related to the principal diagnosis is entered Use the format for inpatient Other bill types Not required Please note that if a surgical procedure is performed and entry is necessary even if the performing physician is the same as the admitting attending physician NPI 77 This field identifies the N number L 77 This field identifies the last name of the operating physician F 77 This field identifies the first name of the operating
54. five occurrences The values for the LMRP are user defined and the NCD is CMS defined ANSI CODES ADJ REASONS Adjustment Reason Codes This is the ANSI reason code that is related to the FISS reason code This is a three digit alohanumeric field with ten occurrences GROUPS Group Codes The group code associated with the ANSI Reason code This is a two digit field with four occurrences Valid values are CO Contractual Obligation CR Correction and Reversals OA Other Adjustment PR Patient Responsibility Palmetto GBA Page 55 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description REMARKS The Remarks describe the reason for non payment This is a five digit alphanumeric field that displays up to four occurrences APPEALS A ANSI Appeals A Code These codes are used for inpatient only This is a five digit alphanumeric field that displays up to 20 occurrences APPEALS B ANSI Appeal B Codes These codes are used for outpatient only This is a five digit alphanumeric field that displays up to 20 occurrences CATEGORY EMC Electronic Media Claim Category Code This field identifies the EMC category of the claim that is returned on a 277 claim response This is a three digit alphanumeric field HC Hard Copy Claim Category Code This field identifies the Hard Copy category of the claim that is returned on a 277 claim response This is a three digit alohanumeric fiel
55. fix to make the DCN unique Pijustimenu ui H In first position system generated Trailer 15 or 16 adjustment ure Area PAS i NE P In first position system generated Post Pay activity R In the first position system generated Trailer 24 with a mask of O for interrupted stay Q Demo Code 62 63 and Qualifying Stay T Unsolicited Adjustments U Unsolicited Trailer 24 Responses Z In first position system generated for trailer 24 with mask N adjustment for incorrect patient status on IPPS claims Mass Adjustment User defined Future Area positions 16 21 reserved for future use 22 23 N A Reserved for future use Palmetto GBA Page 4 September 2015 Section 2 Connection Instructions DDE User s Manual SECTION 2 CONNECTION INSTRUCTIONS Palmetto GBA s DDE system includes the Jurisdiction M Region JM MAC FISS PROD The Jurisdiction M MAC FISS PROD processing region consists of the following states Home Health Hospice HHH North Carolina Alabama Indiana North Carolina South Carolina Arkansas Kentucky Ohio Virginia Florida Louisiana Oklahoma West Virginia Georgia Mississippi South Carolina Illinois New Mexico Tennessee Texas Connection Procedures Once you have a connection established using the instructions provided by your Network Service Vendor the Product Selection Screen will display J URISDICTION M SIGN ON A At the PRODUCT SELECTION screen your cursor will be positioned at the arrow
56. for bill payment Claims awaiting CWF transmission reside in status location S B9000 Part A Response Process Palmetto GBA maintains a holding file containing claims awaiting an initial CWF response S B9099 No manual transaction can be made against these claims Claims cannot be finally adjudicated until a definitive response is received from CWF unless a manual function instructs the system to process the claim without being transferred to CWF Responses aid in processing and proper adjudication of Medicare claims The responses Palmetto GBA receives from the CWF are CWF Edit Error codes that tell us a CWF response is ready to be worked a 5 digit code appears in the lower left corner of the UB04 screen A CWE Disposition Code a 2 digit category or status of claim that indicates Claim is approved Claim is rejected Claims will be retrieved from history Alert codes CWF requests for investigation of overlapping benefits and eligibility status Approved claims Medicare contractor produced provider check and remittance advice Palmetto GBA Page 145 September 2015 Section9 Health Insurance Query for HAS 5 ridic a manuak Rejected claims that require further investigation Medicare contractor reviews these claims makes corrections and resubmits them to CWF Recycled claims which recycle automatically back to CWF The FISS status location definitions are S B90 0 1 transmission S B90 1
57. for each line item ANSI GRP The data for this ANSI Group Code field is from the ANSI file housed as the second page in the Reason Code file The ANSI codes that appear on the line item can be replaced with a new code and the system processes the denial with the entered code The ANSI code is built off of the denial code used for each line item Each denial code must be present on the reason code file to assign the ANSI code to the denial screen This code will occur a maximum of four times ANSI The data for this ANSI Remarks Code field is taken from the ANSI file housed REMARKS as the second page in the Reason Code file The ANSI codes that appear on the line item can be replaced with a new code and the system processes the denial with the entered code The ANSI code is built off the denial code used for each line item Each denial code must be present on the reason code file to assign the ANSI code to the denial screen This code will occur a maximum of four times TOTAL The total of all revenue code non covered units and charges present on MAP171D LINE ITEM The Line Item Reason Codes assigned out of the system for suspending the REASON line item There are a maximum of four 4 FISS reason codes that can be CODES assigned to the line level UB 04 CLAIM ENTRY PAGE 3 Enter the following information onto Page 3 of the Claim Entry screen Figure 45 Payer Information Diagnoses Codes Attending Physician
58. gt in the lower left hand corner Select the number corresponding to A3PTPX and press ENTER B The TPX Sign On screen Figure 1 will display Figure 1 CICS Sign On Screen 1 Atthe USERID prompt type your DDE User ID and press TAB DDE User ID numbers are assigned to individuals at each facility who utilize the DDE system 2 Atthe PASSWORD prompt type in your password and then press ENTER If this is your first time logging on using your new DDE User ID use the default password that was included in your EDI confirmation As you enter your default password nothing will show on the screen but you will see the cursor move to the right After you press ENTER the system will prompt you to change the password Follow the directions noted on the screen regarding password requirements when changing your password Palmetto GBA Page 5 September 2015 Section 2 Connection Instructions DDE User s Manual Note Your password will expire every 30 days and you must make at least 12 password changes before you can repeat a previously used password If you receive a notice that your password has expired please follow the directions noted on the screen when changing your password If you receive a notice that your password has been revoked please refer to the Changing Passwords section If you have not used DDE for several months it may be automatically revoked and please contact the Palmetto GBA EDI Technology Support Cent
59. health agency that submitted the claim DOEBA Date of Earliest Billing Action the first service date of the HHPPS period DOLBA Date of Last Billing Action the last service date of the HHPPS period PATIENT STAT Patient Status Code the patient status code submitted in field 22 of the claim PATIENT IND Patient Indicator Valid values are 0 Episode in good status Final Claim received on time 1 RAP auto cancelled 2 RAP not cancelled Final Claim denied by Medical Review Entire episode cancelled Palmetto GBA Page 151 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 4 Field definitions and completion requirements are provided in the table following Figure 86 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 86 CWF Part A Inquiry Reply Screen Page 4 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code REC Record Number Identifies the MSP segment number MSP Medicare Secondary Payer Identifies the type of MSP record on file Valid values are A Working Aged B ESRD D No Fault E Workers Compensation F PHS Other Federal Agency G Disability H Black Lun
60. indicator column represents a blank If this field is blank all functions are performed as indicated on this chart Function Q RI S T U V WX Y Z Transmitto CWF Y N N Y Y Y Y YNNN Print on Remittance M Y YIN NIY N A Advice 1 Iu ENS ee IdudeonPS amp R Y N NN N NY Y Y YIN Include on Workload YY NIY Y NON Y Y NN USER ACT The User Action Code is used for medical review and reconsideration only CODE The first position is the User Action Code and the second position is the Reconsideration Code The reconsideration user action code will always be R When a reconsideration is performed on the claim the user should enter a R in the second position of the claim user action code or in the line user action code field This tells the system that reconsideration has been performed Valid values include Medical Review A Pay per waiver full technical B Pay per waiver full medical C Provider liability full medical subject to waiver provisions D Beneficiary liability full subject to waiver provisions E Pay claim line full F Pay claim partial claim must be updated to reflect liability G Provider liability full technical subject to waiver provisions H Full or partial denial with multiple liabilities Claim must be updated to reflect liability Full Provider liability medical not subject to waiver provisions J Full Provider
61. is given a status location code beginning with the letter P and is recorded on the claim status inquiry screen A claim cannot be adjusted unless it has been finalized and is reflected on the remittance advice In addition a home health Request for Anticipated Payment RAP TOB 322 cannot be adjusted Providers must be very careful when creating adjustments If you go into the adjustment system and update a claim without making the right corrections the adjustment will still be created and process through the system Errors could cause payment to be taken back unnecessarily No adjustments can be made on the following claims R Rejected claims unless the claim posted to CWF View the TPE TO TPE see Figure 44 field to determine if the claim posted to CWF If there is an X in the TPE TO TPE field the claim did not post to CWF and cannot be adjusted If the TPE TO TPE field is blank or has a value other than X and adjustment can be performed T RTP claims D Denied claims view the reason code narrative to determine if the claim was medically denied or denied for a non medical reason Type of Bill XXP PRO adjustment or XXI Medicare contractor adjustment If a claim has been denied with a full denial the provider cannot submit an adjustment through DDE Any attempted adjustments will reject with Reason Code 30940 a provider is not permitted to adjust a fully medically denied claim If a claim has been fully
62. is not ignored 1 OCE line item denial or rejection is ignored 2 External line item denial Line item is denied even if no OCE edits 3 External line item rejection Line item is rejected even if no OCE edits CWF OVR The CWF Home Health Override field overrides the way the OCE module controls the line item Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description NCD OVR This Override Indicator identifies whether the line has been reviewed for medical necessity and should bypass the National Coverage Determination NCD edits the line has no covered charges and should bypass the NCD edits or the line should not bypass the NCD edits Valid values are Default value The NCD edits are not bypassed A blank in this field is set on all lines for resubmitted RTP d claim Y The line has been reviewed for medical necessity and bypasses the NCD edits D The line has no covered charges and bypasses the NCD edits NCD DOC The National Coverage Determination Documentation Indicator identifies whether the documentation was received for the necessary medical service This indicator will not be reset on resubmitted RTP d claims Valid values are Y The documentation supporting the medical necessity was received N Default Value The documentation supporting the medical necessity was not received NCD RESP The National Coverage Determinati
63. located in the New Password field Type in your new password Nothing will show on the screen as you type but you will see the cursor move to the right After you have finished typing press ENTER Palmetto GBA Page 7 September 2015 Section 2 Connection Instructions DDE User s Manual 3 Verify your new password by typing it identically again in the same New Password field and press ENTER 4 The system displays the TPX Menu Screen Follow via the instructions in Section 2 Connection Instructions above to complete your sign on Note If you receive a notice that your password has been revoked a password utility has been provided for your own password resets Follow the instructions listed below a Proceed to the CDS EDC TPX session screen b Press F5 as shown on the menu at the bottom of screen The Self Service Password Reset screen appears and prompts you to key in a valid RACF ID and PIN c Press ENTER d A message will appear at the bottom of screen providing the new temporary password Press F12 to return to the TPX sign on screen Once returned to the TPX session sign on screen you can now sign on using the new temporary password The password length must be eight 8 characters Passwords must have at least one 1 of these special characters or Passwords must start with a letter and must have at least one 1 number and one 1 letter not a number of special characters NOTE A passwo
64. physician M 77 This field identifies the middle initial of the operating physician SC This field identifies the operating physician s specialty code This information will automatically populate when the claim is submitted Palmetto GBA Page 91 September 2015 Section 5 Claim Entry Field Name UB 04 X Ref DDE User s Manual Description OTH OPR 78 amp This field identifies the Other Operating licensed physician 79 NPI 78 amp This field identifies the NPI number 79 L 78 amp This field identifies the last name of the other operating physician 79 F 78 amp This field identifies the first name of the other operating physician 79 M 78 amp This field identifies the middle initial of the other operating physician 79 SC This field identifies the other operating physician s specialty code This information will automatically populate when the claim is submitted REN PHYS 78 amp This field identifies the rendering physician 79 NPI 78 amp This field identifies the NPI number 79 L 78 amp This field identifies the last name of the rendering physician 79 F 78 amp This field identifies the first name of the rendering physician 79 M 78 amp This field identifies the middle initial of the rendering physician 79 SC This field identifies the rendering physician s specialty code This information will automatically populate
65. roster is transmitted ESRD CMS 382 Form The ESRD attachment form allows ESRD providers to inquire update and enter an ESRD method selection data Select option 57 from the Claim and Attachments Entry Menu Enter a HIC number and function Choose one of the following functions E Entry U Update Inquiry Press ENTER to access the additional fields for entry If a beneficiary is currently on file when you enter an E for the method selection form the system will automatically enter the beneficiary s last name first name middle initial date of birth and sex based on the information stored on the beneficiary file In addition the system should allow access to the provider number dialysis type and selection or change fields ESRD CMS 382 Inquiry screen MAP1391 Field descriptions are provided in the table following Figure 50 MAP1391 JM MAC NC UAT PALMETTO GBA 11501 ESRD CMS 382 INQUIRY MNT HIC METHOD 382 EFFECTIVE DATE FUNCTION LN FN MI DOB SEX PROV NPI TAXO CD FAC ZIP DIALYSIS TYPE NEW SELECTION Y OR CHANGE N OPTION YR CWF ICN CONTRACTOR CWF TRANS DT CWF MAINT DT TIMES TO CWF CWF DISP CD REMARK NARRATIVE 382 EFFECTIVE DATE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 50 ESRD CMS 382 Inquiry Form Field Name HIC Description The beneficiary s Health Insurance Card number Palmetto GBA Page 100 September 2015
66. the Non Wage Federal Amount Ratio AMOUNT This field identifies the total amount TOTAL FEDERAL This field identifies the total Federal amount TOTALS This field identifies the total FED REG Federal Regional This field identifies the amount for columns Wage Amount Wage Index Non Wage Federal Amount Ratio and Amount FED NAT Federal National This field identifies the amount for columns Wage Amount Wage Index Non Wage Federal Amount Ratio and amount TOT FED Total Federal This field identifies amounts for columns Total Federal and Totals Refer to the note for corresponding formats HOSPITAL This field identifies amounts for columns Amount and Totals AMOUNT BLEND AMOUNT This field identifies amounts for columns Wage Index Non Wage Federal Amount Ratio Amount and Totals HSA AMOUNT This field identifies amounts for columns Wage Index Non Wage Amount Federal Amount Ratio Amount and Totals HAS CALC TGT AMT TOT FED OUTLR OPER DSH OPER IME Health Service Area HSA Calculation This field identifies the calculation for HSA 1 HAS FACTOR DRG WT Diagnosis Related Group Weight This field identifies the payment weight of the DRG HAS TOT HSA Total This field identifies the total of the HSA amount multiplied by the DRG Weight Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual DRG Cost Disclosure Inquiry MAP17
67. when the claim is submitted REF PHYS 78 amp This field identifies the Referring Physician This field will be used by all 79 providers as applicable NPI 78 amp This field identifies the National Provider Identifier number 79 L 78 amp This field identifies the last name of the referring physician 79 F 78 amp This field identifies the first name of the referring physician 79 M 78 amp This field identifies the middle initial of the referring physician 79 SC This field identifies the referring physician s specialty code This information will automatically populate when the claim is submitted UB 04 CLAIM ENTRY PAGE 4 The Remarks Page Figure 46 is used to transmit information submitted on automated claims and it gives Palmetto GBA staff a mechanism to make comments on claims that need special consideration for adjudication Providers may utilize Page 4 to Justify claims filed untimely Justify adjustments to paid claims required when using the D9 Condition Code Justify cancels to paid claims Justify other reasons that may delay claim adjudication Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Screen Page 4 MAP1714 Field descriptions are provided in the table following Figure 46 MAP1714 PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY REMARK PAGE HIC S LOC PROVIDER REMARKS 47 PACEMAKER 48 AMBULANCE 40 THERAPY 41 HOME HEALTH 58 HBP
68. 01 Part A South Carolina 11501 Part A North Carolina 11301 Part A Virginia 11401 Part A West Virginia 11004 Home health or hospice PROVIDER NO The six digit number assigned by Medicare to the provider rendering medical service to the beneficiary HOST ID Host IDs are shown as two letter abbreviations for the nine CWF host sites You should access the appropriate host and enter one of the following designations GL Great Lakes MA Middle Atlantic SE Southeast GW Great West PA Pacific SO South KS Keystone NE Northeast SW Southwest APP DATE Date the beneficiary was admitted to the hospital in MMDDYY format This field is not required However entering a date will allow for the most recent information to be provided REASON CODE Indicates the reason for the inquiry Valid codes are 1 Status Inquiry 2 Inquiry relating to an admission A 1 is automatically inserted in this field by the system Change this only if applicable Palmetto GBA September 2015 Page 124 Section 8 Health Insurance Query DDE User s Manual HIQA Page 1 Field descriptions for Page 1 of the HIQA screen are provided in the table following Figure 66 INQUIRY REPLY IP REC 1 DISP CODE 25 UNCONDITIONAL ACCEPT PF1 INQ SCREEN PF3 CLEAR END PF8 NEXT Figure 66 CWF Part A Inquiry Reply Screen Page 1 Field Name Description Claim Number Shows the beneficiary s HIC number
69. 13 September 2015 Section 7 Online Reports DDE User s Manual Credit Balance Report R3 FORM 838 Inquiry Screen MAP1B21 Field descriptions are provided in the table following Figure 58 JM MAC SC HHH UAT 11001 CREDIT BALANCE REPORT FORM 838 INQUIRY PROVIDER STARTING HIC 838 ENTRY HIC BENEFICIARY NAME FROM THRU QUARTER NUMBER LAST FI TOB DATE DATE ENDING PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 58 R3 Credit Balance Report Form 838 Inquiry Field Name Description PROVIDER This field displays the six digit provider number issued by CMS STARTING HIC This field identifies the beneficiary s Medicare number as shown on the Medicare card 838 ENTRY This field identifies the 838 Entry field Valid values are Y Yes N No Note When this field is populated with a Y the credit balance entry screen is displayed and allows the provider to enter a new record Note This option is not currently support by Palmetto GBA HIC NUMBER This field identifies the beneficiary s Medicare number as shown the Medicare cared BENEFICIARY This field displays the beneficiary s last name and the initial of the first name NAME LAST FI TOB This field displays the Type of Bill for a particular period of care FROM DATE Statement From Date This field identifies the beginning date of service for the period included on the claim in MMDDYY format THRU DATE Statement
70. 3 DRG COST DISCLOSURE INQUIRY VERSION PPS HOSPITAL FROM DT THRU DT OPERATING PORTION COST OUTLIER CASE MIX COST TO CHARGE LOW VOL BLEND RATIO BLEND RATIO THRESHOLD INDEX RATIO PYMNT TARGET DRG REG NAT TARGET WAGE AMOUNT NON WAGE AMOUNT AMOUNT NATIONAL REGIONAL NATIONAL REGIONALI WAGE WAGE NON WAGE FED TOTAL AMOUNT INDEX AMOUNT RATIO AMOUNT FEDERAL TOTALS FED REG FED NAT TOT FED HOSPITAL AMOUNT BLEND AMOUNT HSA AMOUNT HSA CALC TGT AMT TOT FED OUTLR OPER DSH OPER IME 1 HSA FACTOR DRG WT HSA TOT PRESS PF3 FOR DRG PPS INQUIRY PF7 FOR PREV PAGE PF8 FOR NEXT PAGE Figure 21 DRG Cost Disclosure Inquiry Field Name Description PVDR Displays the provider number VERSION This field identifies the program version number for the Pricer program used D DT The date for which the DRG information is being selected MMDDYY Format FROM DT The beginning date of service MMDDYY Format THRU DT The ending date of service MMDDYY Format Operating Portion COST OUTLIER This field identifies the cost outlier threshold amount which is the standard THRESHOLD operating threshold for computing cost outlier payments CASE MIX INDES This field identifies the case mix index from the operating PPS base year COST TO This field identifies the Cost to Charge ratio of operating cost to charges CHARGE RATIO LO VOL PYMNT This field identifies the low volume payment amount calculated by the IPPS Pricer BLEND
71. 3 to return to the selection screen Any changes made to the screens will not be updated Press F9 to update enter the claim into DDE for reprocessing and payment consideration If the claim still has errors reason codes will appear at the bottom of the screen Continue the correction process until the system takes you back to the Claim Correction Summary Note The online system does not fully process a claim It processes through the main edits for consistency and utilization The claim goes as far as the driver for duplicate check The claim will continue forward when the nightly production batch is run Potentially the claim could RTP again in batch processing When the corrected claim has been successfully updated the claim will disappear from the screen The following message will display at the bottom of the screen PROCESS COMPLETED ENTER NEXT DATA SUPPRESSING RTP CLAIMS A feature exists within DDE that allows a claim to be suppressed because RTP claims do not purge from the FISS for 60 days or longer This is a helpful function for RTP claims filling up unnecessary space under the Claim Correction Menu option This action will hide from view the claims in the Claim Correction Menu option however all claims will continue to display through the Inquiry Menu option until they purge from the system Type a Y in the SV field located in the upper right hand corner of page 1 and then press F9 The system will return you to the
72. 4 Figure 31 DDE OSC Repository Inquiry seen nennen nennen 56 Figure 32 Claim Summary Totals Inquiry Screen eseseseeseeeeeeeee eene ener 57 Figure 33 Home Health Payment Totals Inquiry Screen esee 59 Figure 34 ANSI Related Reason Codes Inquiry Selection Screen see 60 Figure 35 ANSI Related Reason Codes Inquiry Selection Screen ANSI Reason Code List 61 Figure 36 ANSI Standard Codes Inquiry Screen eese eene eene 61 Figure 37 Check History SCreeti sscics cseszesadsesdesiubesiss e rere eri ILI Ropa Ix EE ee Heo pe vog HER e Ex gv o Fe LE Era sue Pu 63 Figure 38 ICD 10 CM Code Inquiry Screen eese enemies 64 Figure 39 Claim and Attachments Entry Menu essent ener 66 Figure 40 UB 04 Claim Entry Screen Page 1 sees eene rennen 67 Figure 41 UB 04 Claim Entry Revenue Screen esee enne nee ener 71 Figure 42 UB 04 Claim Entry Page 2 Additional NPI lines eene 73 Figure 43 UB 04 Claim Entry Page 2 Line Level Reimbursement eene 74 Figure 44 UB 04 Claim Entry Page 2 Additional Detail esee 81 Figure 45 UB 04 Claim Entry Page Sociis naines raian iE i tnnt E enne 89 Figure 46 UB 04 Claim Entry Page 4 eene nennen nee rennen rennen enne 93 Figure 47 UB 04 C
73. 5J Patient eligibility information on preventative care in the FISS Screen 5 MAP175M Patient eligibility information on preventive HCV screening Screen 6 MAP1755 Patient hospital eligibility information Screen 7 MAP1756 Patient HMO Enrollment and other eligibility information Palmetto GBA Page 10 September 2015 Section 4 Claim Inquiry DDE User s Manual Screen 8 MAP1757 Patient PAP and Mammography eligibility information Screen 9 MAP1758 Patient Hospice Benefit periods 1 and 2 Screen 10 MAP175C Patient Hospice Benefit periods 3 and 4 Screen 11 MAP175K Patient Smoking and Tobacco Use Cessation Counseling Services Screen 12 MAPI75L Patient Home Health certification information To begin the inquiry process enter the following information on screen 1 as it appears on the patient s Medicare card Health Insurance Claim HIC number Last name amp first initial Sex M or F Date of birth in MMDDY YY Y format TAB to move between fields on the screen Only press ENTER when all fields have been completed Beneficiary CWF Screens Screen 1 MAP1751 Field descriptions are provided in the table following Figure 6 MAP1751 JM MAC SC HHH UAT 11001 ELIGIBILITY DETAIL INQUIRY HIC CURR XREF HIC PREV XREF HIC TRANSFER HIC C IND LTR DAYS LN FN MI SEX DOB ADDRESS 1 2 3 4 5 6 ZIP CURRENT ENTITLEMENT PART A EFF DT TERM DT PART B EFF DT TERM DT CURRENT BENEFIT PERIOD
74. 6 Figure 17 Beneficiary CWF Screen 12 sese nnne netten nein rennen 27 Figure 18 DRG PPS Inquiry Screen eese eene eene tente nne nnne tne tn trennen eren trennen 28 Figure 19 DRG PPS Inquiry Screen 4 onte rere i e Roe er eph eoa P DE ene ae EE Ene kasd eda 32 Figure 20 DRG Cost Disclosure Inquiry esses enne nne 35 Palmetto GBA Page ii September 2015 DDE User s Manual Table of Contents Figure 21 DRG Cost Disclosure Inquiry eese nnne ener ren rennen ener 37 Figure 22 DRG Cost Disclosure Inquiry sees ener nennen rennen enne 39 Figure 23 DRG Cost Disclosure Inquiry eese eene rennen rennen enne 40 Figure 24 Claim Summary Inquiry Screen sesessesesseeseeeeeeeeenee nennen enne 43 Figure 25 Revenue Code Table Inquiry Screen eeeeesessesseeseeeeeeeeeeen nennen rennen enne 45 Figure 26 HCPC Inquiry SCreen ien ete ee roget tpi Deep ke baee espe e c ubl peel beso PESENE aE Lage Pared 46 Figure 27 ICD 9 CM Code Inquiry Screen eeeeessesseesseeeeeee ener ener nre 50 Figure 28 Adjustment Reason Codes Inquiry Selection Screen eee 51 Figure 29 Reason Codes Inquiry Screen Example 1 sese ene en en 52 Figure 30 ANSI Related Reason Codes Inquiry Screen cee ceecescseeceseeeeeeeeeeeeseeeaeecaaecaeenaeenaeenaeee 5
75. 63 316 Errors on Initial Bills Scroll Left View sees 120 Figure 64 316 Errors on Initial Bills Scroll Right View eee 120 Figure 65 CWF Beneficiary Inquiry Screen 0 0 cee ceeceeceseceeeeeeeeeeeeeeaceeaeeeaaecsaecaeceaeesseenseeeneeeseeeneeeees 123 Figure 66 CWF Part A Inquiry Reply Screen Page 1 125 Figure 67 CWF Part A Inquiry Reply Screen Page 2 ssesesssesseeeeeeeeeeee nennen 128 Figure 68 CWF Part A Inquiry Reply Screen Page 3 esssessssseseeeeeeeeeeeee eene 130 Figure 69 CWF Part A Inquiry Reply Screen Page 4 sesssssssesseeeeeeee eene eene een 131 Figure 70 CWF Part A Inquiry Reply Screen Page 5 sse 132 Figure 71 CWF Part A Inquiry Reply Screen Page 6 sssssesseeeeeeeeneren rennen nennen 133 Figure 72 CWF Part A Inquiry Reply Screen Page 7 eeeseesssseeeeeeeeeenrenen ener 133 Palmetto GBA Page iii September 2015 DDE User s Manual Table of Contents Figure 73 CWF Part A Inquiry Reply Screen Page 8 eese nennen 135 Figure 74 CWF Part A Inquiry Reply Screen Page 9 sssssssssesseeseeeeeeeee nne neeneeneenne 136 Figure 75 CWF Part A Inquiry Reply Screen Page 10 137 Figure 76 CWF Part A Inquiry Reply Screen Page 11 eese 138 Figure 77 CWF Part A Inquiry Reply Screen Page 12 sseseseseseeeeeeeeeenee een
76. 84 Field descriptions are provided in the table following Figure 22 JM MAC VA WV UAT 11003 DRG COST DISCLOSURE INQUIRY VERSION PPS HOSPITAL FROM DT THRU DT CAPITAL PORTION LOW VOL COST OUTLIER THRESHOLD COST TO CHARGE RATIO PYMNT PAYMENT METHODOLOGY FEDERAL GEOG ADJUSTED LARGE BLEND NEW OLD HOSPITAL ADJ FEDERAL URBAN RATIO CAPITAL CAPITAL SPECIFIC FACTOR RATE ADD ON HOSP FED RATIO PAYMENT RATE HOSPITAL TOTAL FEDERAL AMOUNT TOTAL HOSPITAL AMOUNT TOTAL PRESS PF3 FOR DRG PPS INQUIRY PF7 FOR PREV PAGE PF8 FOR NEXT PAGE Figure 22 DRG Cost Disclosure Inquiry Field Name Description PVDR Displays the provider number VERSION This field identifies the program version number for the Pricer program used D DT The date for which the DRG information is being selected MMDDYY Format FROM DT The beginning date of service MMDDYY Format THRU DT The ending date of service MMDDYY Format Capital Portion COST OUTLIER COST TO CHARGE RATIO THRESHOLD This field identifies the cost outlier threshold amount which is the standard operating threshold for computing cost outlier payments This field identifies the Cost to Charge ratio of operating cost to charges LOW VOL PYMT This field identifies the low volume payment amount calculated by the IPPS Pricer FEDERAL RATE PAYMENT This field identifies the capital PPS payment methodology METHOLODOGY GEOG ADJ Geographical Adjust
77. A and enter the name of the individual insured under a supplemental policy on line B Note MSP claims cannot be submitted or corrected in DDE REL 59 A On the same lettered line A B or C that corresponds to the line on which A C B C Medicare payer information is reported enter the code indicating the relationship of the patient to the identified insured The following codes are for Medicare requirements only Other payers may require codes not reflected Refer to your UB 04 Manual for valid values CERT SSN 60 A Enter the patient s Health Insurance Card Number HICN if Medicare is the HIC ID B C primary payer A C SEX The sex of the beneficiary patient Refer to your UB 04 Manual for valid A C values GROUP NAME 61 A Enter the name of the group or plan through which that insurance is A C B C provided Entry required if applicable DOB The insured s date of birth in MMDDCCYY format INS GROUP 62A Not displayed on new claims MSP claims cannot be submitted in DDE If NUMBER B C viewing this page through the claims inquiry menu and an MSP claim was A C submitted this field identifies the Insurance Group identification number control number or code assigned by that health insurance company to identify the group under which the insured individual is covered TREAT AUTH 63A The HHPPS Treatment Authorization Code for home health claims CODE B C identifies a matching key to the
78. ADR letter for claims in the ADR status location 1 Type S B6 in the S LOC field 2 Press ENTER and all claims in an S B6000 or S B6001 status location will display 3 Type an S in the SEL field of the desired claim and press ENTER 4 The ADR letter immediately follows claim page 6 MAP1716 The ADR will consist of 2 pages Note Do not use the F9 function key with these claims If you press F9 the FISS will generate a new ADR Palmetto GBA Page 42 September 2015 Section 4 Claim Inquiry DDE User s Manual Claim Summary Inquiry screen MAP1741 Field descriptions are provided in the table following Figure 24 MAP1741 JM MAC SC HHH UAT 11001 CLAIM SUMMARY INQUIRY NPI HIC PROVIDER S LOC TOB OPERATOR ID FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Figure 24 Claim Summary Inquiry Screen Field Name Description NPI This field identifies the National Provider Identifier number HIC Type the health insurance claim number to view a particular beneficiary s claims data PROVIDER Your Medicare ID number will automatically display Note If your facility has sub units aliases e g SNF ESRD CORF ORF the provider number of the sub unit must be typed in this field If the correc
79. ARRATIVE TOTAL The total number of reported claims being returned to the provider listed in the RETURNED Provider field CLAIMS TOTAL The total amount of charges for claims returned to the provider listed in the RETURNED Provider field CHARGES 201 Report Pended Processed and Returned Claims Figures 61 and 62 show the left view and right view of the Pended Processed and Returned Claims report The fields described in the table following the figures display for Inpatient Outpatient and Lab Pended Claims Palmetto GBA September 2015 Page 116 Section 7 Online Reports DDE User s Manual Report View Inquiry MAP1661 Scroll Left View Field descriptions are provided in the table following Figure 62 MAP1661 JM MAC VA WV UAT 11003 ACMMA951 08 28 15 REPORT VIEW INQUIRY C201534P 17 53 46 REPORT FREQUENCY SCROLL KEY PAGE SEARCH REPORT 201 MEDICARE PART A 11 CYCLE DATE 8 21 15 SUMMARY OF PENDED CLAIM BLUE CROSS CODE INPATIENT RECD ADMIT NAME MED REC NUMBER HIC NUMBER DATE DATE 04 29 15 05 05 15 0 PAT CONTROL NBR 06 10 15 06 11 15 0 PAT CONTROL NBR 06 10 15 07 04 14 0 PAT CONTROL NBR MED CWFR MEDICAL CHF REGULAR CLAIMS COUNT 0 TOTAL CHARGES 0 00 ADJUSTMENTS COUNT 0 TOTAL CHARGES f 0 00 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 61 201 Pended Processed and Returned Claims Scroll Left View Report View Inquiry MAP1661 Sc
80. ATIO Operating indirect medical education ratio five digit field in 9 9999 format OPERATING CAPITAL XIX RATIO XIX ratio five digit field in 9 9999 format SSI RATIO Supplemental security income ratio which determines if the hospital qualifies for a disproportionate share adjustment five digit field in 9 999 format NEW PROVIDER Displays whether or not the provider is a New Provider URBAN RURAL The type and location of the hospital and is determined by the DRG pricer eleven digit alphanumeric field Valid values are Large Urban Other Urban Rural NUMBER OF The number of beds in the facility six digit field in 999999 format BEDS LOW VOL Amount calculated by the inpatient prospective payment systems IPPS Pricer is PYMNT an estimated interim payment This estimated interim low volume payment amount will be adjusted at cost report settlement if any of the payment amounts upon which the low volume payment amount is based are recalculated at cost report settlement for example payments for disproportionate share hospital DSH indirect medical education IME or federal rate versus hospital specific rate payments for sole community hospitals Medicare dependent hospitals DISPROPORTIO The disproportionate share amount five digit field in 9 9999 format NATE SHARE RELATIVE The relative weight amount six digit field in 99 9999 format WEIGHT ALOS Average length of stay Identifies the CMS predet
81. COLORECTAL G0120 04022002 04022002 DIABETES 82951 01012005 COLORECTAL G0121 07012001 07012001 GLAU G0117 G0118 01012002 FOB TEST 80107 04022002 04022002 MAMM G0202 G0203 04012001 FOB TEST 60328 01012004 01012004 MAMM 76092 01011998 FOB TEST 82270 01012007 01012007 MAMM 77057 01012007 IPP EXAM G0344 SRVNOELG SRVNOELG PAPT P3000 G0123 07012001 07012001 IPP EXAM G0366 SRVNOELG SRVNOELG G0143 G0144 IPP EXAM 60367 SRVNOELG 00000000 G0145 G0147 IPP EXAM G0368 00000000 SRVNOELG G0148 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 71 CWF Part A Inquiry Reply Screen Page 6 HIQACOP CWF PART INQUIRY REPLY PAGE 07 OF 19 IP REC CN NM IT DB INT 11004 PREVENTIVE SERVICE TECH DTE PROF DTE MMDDCCYY MMDDCCYY AAA G0389 07012007 07012007 IPP EXAM G0402 SRVNOELG SRVNOELG PREVENTIVE SERVICE TECH DTE PROF DTE IPP EXAM G0403 SRVNOELG SRVNOELG MMDDCCYY MMDDCCYY IPP EXAM G0404 SRVNOELG 00000000 IPP EXAM G0405 00000000 SRVNOELG PTWR G9143 08032009 08032009 AWV G0438 00000000 01012011 AWV G0439 00000000 01012011 HCAS G0472 06022014 06022014 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 72 CWF Part A Inquiry Reply Screen Page 7 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial Fir
82. CROLL FWD PF7 PREV PAGE PF8 NEXT PAGE Figure 9 Beneficiary CWF Screen 4 Field Name Description HIC The beneficiary s Medicare number as it appears on the Medicare ID card NM The beneficiary s last name IT The initial of the beneficiary s first name DB The beneficiary s date of birth in MMDDYY format SX The beneficiary s sex Valid values are F Female M Male PRVN SRVC This field identifies the preventative service category TECH D Technical Date This field identifies the date the beneficiary is eligible for preventative service coverage Note When there is not a date one of the following messages displays to explain why the beneficiary is not eligible Valid values are PTB Beneficiary is not entitled to Part B RCVD Beneficiary already received service DOD Beneficiary not eligible due to date of death GDR Beneficiary not eligible due to gender AGE Beneficiary not eligible due to age Palmetto GBA Page 15 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description SRV Beneficiary not eligible for the service VAC Beneficiary already vaccinated Service not applicable PROF D Professional Date This date identifies the date the beneficiary is eligible for preventative service coverage Note When there is not a date one of the following messages displays to explain why the beneficiary is not eligible Valid values are
83. Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA TECH Technical PROF Professional PULMONARY The total number of technical and professional Pulmonary Rehabilitation services REMAINING remaining CARDIAC The total number of professional and technical Cardiac Rehabilitation services used APPLIED ICR APPLIED The total number of professional and technical Intensive Cardiac Rehabilitation Services used Palmetto GBA Page 137 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 11 Field descriptions for Page 11 of the HIQA screen are provided in the table following Figure 76 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 76 CWF PartA Inquiry Reply Screen Page 11 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor N
84. Claim Summary Inquiry screen Palmetto GBA Page 107 September 2015 Section 6 Claim Correction DDE User s Manual NOTE This action CANNOT be reversed which means the claim cannot be reactivated Be sure that you want to perform this function before doing so CLAIMS SORT OPTION DDE claims are normally displayed in type of bill order depending on the two digit number selected from the Claim and Attachments Correction Menu The claim sort option allows a provider to choose the sort order To sort the DDE claims type one of the following values in the DDE SORT field and press ENTER M Displays claims in Medical Record Number order The dual purpose field labeled PROV MRN will display the provider number unless you choose this sort option N Displays claims in the beneficiary last name order H Displays claims in Health Insurance Claim HIC number order R Displays claims in Reason Code order D Displays claims in Receipt Date order Claims and Attachments Corrections ADJ USTMENTS When claims are keyed and submitted through DDE or the electronic claims filing system for payment consideration the user can sometimes make entry mistakes that are not errors to the DDE FISS system As a result the claim is processed through the system to a final disposition and payment To change this situation the on line claim adjustment option can be used to submit adjustments for previously paid finalized claims After a claim is finalized it
85. DATA FRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYS SNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS PSYCHIATRIC PSY DAYS REMAIN PRE PHY DAYS USED PSY DIS DT INTRM DT IND PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF8 NEXT PAGE Figure 6 Beneficiary CWF Screen 1 Field Name Description HIC Type the patient s health insurance claim HIC number as it appears on the Medicare ID card CURR XREF HIC If the HIC number has changed for the beneficiary patient this field represents the most recent number the HIC number as returned by CWF PREV XREF HIC This field is no longer in use TRANSFER HIC This field is no longer in use C IND Century Indicator This field represents a one position code identifying if the patient s date of birth is in the 18 19 or 20 century Valid values are 8 1800s 9 1900s 2 2000s LTR DAYS The lifetime reserve days remaining LN The patient s last name Palmetto GBA Page 11 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description FN The patient s first name MI The patient s middle initial SEX The patient s sex DOB The patient s date of birth in MMDDYYYY format DOD The patient s date of death ADDRESS The patient s street address city and state of residence 1 6 ZIP The zip code for state of residence Current Entitlement PART A EFF DT The date a benefic
86. DATE The date the hospice benefit period was terminated OWNER CHANGE The start date of a change of ownership within the period for the second Provider ST DATE PROV The second hospice s Medicare provider number INTER The second hospice s Medicare Contractor number 1ST BILLED DT The date of each earliest hospice bill date in MMDDYY format LAST BILLED DT Each most recent hospice bill date inr MMDDYY format DAYS BILLED Number of hospice dates used for each hospice period REVO IND The revocation indicator per hospice period Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description Period 2 or 4 PERIOD The Hospice Benefit Period Number Valid values are 1 First time a beneficiary uses hospice benefits 2 Second time a beneficiary uses hospice benefits 1ST START DATE The beneficiary s effective period with the Hospice Provider MMDDYY format PROV The hospice s Medicare provider number INTER The hospice s Medicare Contractor number OWNER CHANGE The start date of a change of ownership for the first Provider within the election ST DATE period PROV The number of the Medicare hospice Provider INTER The hospice s Medicare Contractor number 2ND START DATE The date the second benefit period began PROV The second hospice s Medicare provider number INTER The second hospice s Medicare Contractor number TERM DATE The date the hospice
87. DT TERM DT B CURR ENT DT TERM DT PRI ENT DT TERM DT LIFE RSRV PYSCH CURRENT BENEFIT PERIOD DATA FRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYS SNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS PRIOR BENEFIT PERIOD DATA FRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYS SNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS CURR B YR CASH BLOOD PSYCH OT PRIR B YR CASH BLOOD PSYCH OT PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 11 Beneficiary CWF Screen 6 Field Name Description CLAIM The beneficiary s Medicare number as it appears on the Medicare ID card NAME The beneficiary s first initial and last name D O B The beneficiary s date of birth in MMDDYY format Palmetto GBA Page 17 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description SEX Valid values are F Female M Male U Unknown INTER The Medicare contractor number for the Provider PROV The CMS assigned identification number of the institution that rendered services to the beneficiary patient It is system generated for external operators that are directly associated with one Provider as indicated on the operator control file PROV IND Provider Indicator This field identifies the provider number indicator This is a one digit alphanumeric field The val
88. Demand Reversal field identifies that an SNF demand claim has been reversed Valid values are P Partial reversal it is the operator s responsibility to reverse the charges and days to reflect the reversal F Full reversal the system reverses all charges and days REJ CD The Reject Code identifies the reason code for which the claim is being denied MR HOSP The Medical Review Hospice Reduced field identifies for hospice bills the RED line item s that have been reduced to a lesser charge by medical review Valid values are Not reduced Y Reduced RCN IND The Reconsideration Indicator is used only for home health claims Valid values include A Finalized count affirmed B Finalized no adjustment count pay per waiver R Finalized count reversal adjustment U Reconsideration MR HOSP RO The Medical Review Regional Office Referred field identifies for RO Hospice bills if the claim has been referred to the Regional Office for questionable revocation Valid values are Not referred Y Referred ORIG UAC Original User Action Code This field identifies the original user action code It is populated updated when the claim level user action code is populated updated This is a two digit alohanumeric field MED REV The Medical Review Reasons field identifies a specific error condition RSNS relative to medical review There are up to nine medical review reasons that can be captured per claim This field displays me
89. E ENTER DATA OR PRESS PF3 TO EXIT Figure 3 The Main Menu Sign Off Procedures To end communication between your terminal and Palmetto GBA s host system FISS you must sign off The terminal will sign off automatically when the network is disabled To help the computer function at optimum speed always sign off completely and correctly when you are not using the system 1 Press F3 from the Main Menu 2 The screen will display SESSION SUCCESSFULLY TERMINATED J URISDICTION M SIGN OFF A Type CESF LOGOFF over the message and press ENTER B Type K to sign off from the TPX Menu Screen and press ENTER 3 Pull down the Terminal menu from the toolbar and select Disconnect 4 Pull down the Terminal menu again and select Close Changing Passwords J URISDICTION M PROVIDERS Your password will expire every thirty days On the day after it expires when you type your password the system will automatically prompt you to change your password Rules for passwords will display on the system when you change your password To change your password follow these steps 1 When you log on for the first time or after your password has expired you will enter your user ID and your existing or default password After pressing ENTER the system will display the message Your password has expired Please enter your new password The screen will now contain one New Password field 2 Your cursor will be
90. ENTER to complete the exit process Scrolling Backwards in a Screen Page Not all information on a page may be seen F5 on the screen at one time To review hidden data from the same screen page press F5 to scroll backwards Scrolling Forward in a Screen Page To view hidden data from the same screen F6 page press F6 to scroll forward F7 View Previous Page Press F7 to review a previous page or move backward one page at a time F8 Page Forward Press F8 to view the next page or to move forward one page at a time Updating Data Due to the system s design a claim will not be accepted until either F9 all front end edits are corrected or the system is instructed to reject or return the claim By pressing F9 the system will return claim errors for correction and update and store data entered while in the entry or correction transaction mode F10 Scroll Left Moves left to columns 1 80 within a claim record This also allows access to the last page of beneficiary history when in claim summary by HIC F11 Scroll Right Moves right to columns 81 132 Status Location Codes The Status Location S LOC code for Medicare DDE screens indicates whether a particular claim is paid suspended rejected returned for correction etc The six character alphanumeric code is made up of a combination of four sub codes the claim status processing type location and additional location i
91. F field will direct you to the field that correlates to the UB 04 form noted in the manual TRANSMITTING DATA When claim entry is completed press F9 to store the claim and transmit the data Tf any information is missing or entered incorrectly the DDE system will display reason codes on the bottom left side of the claim screen to alert you of any errors that need to be corrected The claim will not transmit until it is free of front end edit errors A blank claim entry screen will display if the claim is successfully transmitted Correcting errors Press F1 to see an explanation of the reason code After reviewing the explanation press F3 to return to your claim and make the necessary correction s If more than one reason code appears continue this process until all reason codes are eliminated and the claim is successfully captured by the system If more than one reason code is present pressing F1 will always bring up the explanation of the first reason code unless the cursor is positioned over one of the other reason codes Working through the reason codes in the order they are listed is the most efficient method Eliminating the reason codes at the beginning of the list may result in the reason codes at the end of the list being corrected as well Note The system will automatically enter your provider number into the OSCAR field If the facility has multiple provider numbers you will need to change the provider number to
92. ICD 9 code is listed review the most current effective date and termination date To make additional ICD 9 CM inquiries type new information over the previously entered data To inquire about an ICD 9 CM procedure code type the letter P followed by the three or four digit procedure code in the STARTING ICD9 CODE field Do not type the decimal point or zero fill the code If the code entered requires a fourth and or firth digit an asterisk will appear after the description If an invalid code is entered the system will select the nearest code Palmetto GBA Page 49 September 2015 peocpun c Sie LL EEEE EEE E EE EE Duc usar s Manual ICD 9 CM Code Inquiry Screen MAP1731 Field descriptions are provided in the table following Figure 27 MAP1731 JM MAC SC HHH UAT 11001 SC ICD 9 CM CODE INQUIRY STARTING ICD9 CODE ICD9 CODE DESCRIPTION EFFECTIVE TERM DATE EFFECTIVE TERM DATE EFFECTIVE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 27 ICD 9 CM Code Inquiry Screen Field Name Description STARTING To view all ICD 9 CM codes press ENTER in this field The ICD 9 CM code is ICD 9 CODE used to identify a specific diagnosis ses or inpatient surgical procedure s relating to a bill which may be used to calculate payment i e DRG or make medical determination relating to a claim ICD 9 CODE The specific ICD 9 code to be viewed DESCRIPTION A description of ICD 9 code EFFECTIVE The effective date of the program a
93. IDENTIFY MA05 101603 INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL EN MA06 080104 INCORRECT BEGINNING AND OR ENDING DATE S ON CLAIM MA07 110407 THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO MEDICAID F MA08 110407 YOU SHOULD ALSO SEND THIS CLAIM TO THE PATIENT S OTHER INSU MA09 110407 CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED YO MA10 110407 THE PATIENT S PAYMENT WAS IN EXCESS OF THE AMOUNT OWED YOU MA100 110407 MISSING INCOMPLETE INVALID DATE OF CURRENT ILLNESS INJURY MA101 110407 A SKILLED NURSING FACILITY SNF IS RESPONSIBLE FOR PAYMENT MA102 080104 MISSING INCOMPLETE INVALID NAME OR PROVIDER IDENTIFIER FOR MA103 110407 HEMOPHILIA ADD ON MA104 013104 MISSING INCOMPLETE INVALID DATE THE PATIENT WAS LAST SEEN O PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD gt gt rrrrrrrrrrrr gt Figure 35 ANSI Related Reason Codes Inquiry Selection Screen ANSI Reason Code List 2 Press ENTER to display the ANSI Standard Codes Inquiry screen see Figure 36 ANSI Standard Reason Codes Inquiry Screen MAP1582 Figure 36 Field descriptions are provided in the table following Figure 36 MAP1582 JM MAC SC HHH UAT 11001 ACMFA891 08 26 15 ANSI STANDARD REASON CODES INQUIRY C201534P 17 10 46 MNT SYSTEM 03 24 08 RECORD TYPES ARE C ADJ REASONS G GROUPS R REMARKS A APPEALS T CLAIM CATEGORY S CLAIM STATUS RECORD TYPE 7 A TE
94. IT PF5 UP PF6 DN PF7 PRE PF8 NXT PF9 UPDT PF10 LT PF11 RT Figure 42 UB 04 Claim Entry Page 2 Additional NPI lines Field Name rA Description NDC CD PAGE There are a total of 33 pages to account for 450 revenue lines Press F6 01 to advance to the next page The page number will change each time you ress F6 HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system PROVIDER 57 This field displays the provider identification number CL 1 7 This field identifies the claim line number NDC FIELD This field identifies the National Drug Code NDC NDC This field identifies the NDC quantity QUANTITY QUALIFIER This field identifies the NDC quantity qualifier RETURN This field identifies the HIPPS codes returned from the QIES Response file HIPPS1 This is a five digit alphanumeric field RETURN This field identifies the HIPPS code returned from the QIES response file HIPPS2 This is a five digit alphanumeric field LLR NPI This field identifies the ine level rendering physician s NPI number L The last name of the rendering physician F The first
95. J AMT SEX C I MAJOR DIAG CAT DIAG CD USED LTR DAYS 5 POA 5 NPI PROV OR AGE PAT LIAB GROUPER VERSION RETURN CODE SEC DIAG USED PRICER VERSION PF3 EXIT PF6 FWD PF8 COST DISC PF10 LEFT Figure 19 DRG PPS Inquiry Screen The following fields on this screen will remain the same as the data that was entered on MAP1781 in Figure 18 Field Name Description DIAGNOSES Diagnosis Codes Seven character alphanumeric fields that identify up to nine 1 9 codes for coexisting conditions on a particular claim The admitting diagnosis is not entered PROCEDURES Procedure Codes Required for inpatient claims Seven digit field identifying the 1 9 principle procedure first and up to eight additional procedures POA This field identifies the last character of the Present on Admission POA indicator Valid values are Z The end of POA indicators for principal and if applicable other diagnoses X The end of POA indicators for principal and if applicable other diagnoses in special processing situations that may be identified by CMS in the future Not acute care POA s do not apply NPI The provider s National Provider Identifier NPI number SEX The Beneficiary s Sex C l Century Indicator If you enter D O B date of birth you must enter the century indicator Valid values are 8 1800 1899 9 1900 1999 2 2000 DISCHARGE The Patient s Discharge Status Cod
96. MIT DATE HR TYPE SRC D HM COND CODES 01 02 03 04 05 06 07 08 OCC CDS DATE 01 02 06 07 SPAN CODES DATES 01 05 09 VALUE CODES AMOUNTS MSP APP IND 02 05 08 lt REASON CODES PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF8 NEXT PF9 UPDT Figure 53 UB 04 Claim Entry Page 1 Press F1 to access the Reason Code file Figure 53 The system automatically pulls up the first reason code with its message The message will identify the fields that are in error and will suggest corrective action Press F3 to return to the claim or type in an additional reason code and press ENTER Palmetto GBA Page 106 September 2015 Section 6 Claim Correction DDE User s Manual Reason Codes Inquiry Screen MAP1881 Field descriptions are in the table following Figure 29 of this manual MAP1881 JM MAC SC HHH UAT 11001 SC REASON CODES INQUIRY MNT PLAN REAS NARR EFF MSN EFF TERM EMC HC PRO PP CC IND CODE TYPE DATE REAS DATE DATE ST LOC ST LOC LOC IND HD CPY A B NB ADR PROCESS COMPLETED NO MORE DATA THIS TYPE PRESS PF3 EXIT PF6 SCROLL FWD PF8 NEXT Figure 54 Reason Codes Inquiry Screen Type Information The reason codes may be accessed from any claim screen The Inquiry screen can be accessed by typing the option number in the SC field in the upper left hand corner of the screen For example type 15 in the SC field to access the DX PROC Codes screen Press F3 to return to the claim Press F
97. Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms 18 Infectious and Parasitic Diseases Systemic or Unspecified Sites 19 Mental Diseases and Disorders 20 Alcohol Drug Use and Alcohol Drug Induced Organic Mental Disorders 21 Injuries Poisonings and Toxic Effects of Drugs 22 Burns 23 Factors Influencing Health Status and Other Contacts with Health Services 24 Multiple Significant Trauma 25 Human Immunodeficiency Viral Infections RETURN CODE The Return Code reflects the status of the claim when it has returned from the Grouper Program This is a one digit alphanumeric field PROC CD USED Procedure code s that identifies the principal procedure s performed during the billing period covered by the claim Required for inpatient claims DIAG CD USED Identifies the primary diagnosis code used by the Grouper program for calculation SEC DIAG USED Diagnosis code used by the Grouper program for calculation The Returned from Pricer data displayed on this screen will be as follows Field Name Description GROUPER The program identification number for the Grouper program used VERSION PRICER The program version number for the Pricer program used VERSION Palmetto GBA Page 34 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description UNCOMP CARE Uncompensated Care Payment Amount This is the amount publishe
98. N 41 Performing Claims Inquiries eese eere eene nnne tne en tren rennen 42 Viewing an Additional Development Request ADR Letter eseeeeeeeeeenen 42 Revenue Codes miea a eA ted DE M LM M M RM 45 HCPC ngt cm aE 46 Diagnosis amp Procedure Code Inquiry ICD 9 oo ieee cescceseceseceseceeeeeeeeeceeseaeecaeeeaeecaaecsaessaeeeaeeeaeees 49 Adjustment Reason Code Inquiry esses ener nennen nennen nennt nnne nnne 50 Reason Codes nquity cort iere ront niesen exte Iba ee reed Ended PEE eo Reese tee eb esee aede Ee lease 52 OSC voids D 56 Claims Count Summary nipote lp teorie LE eria te lie ege euge LEE Ee eph LEE REOR ERE aaa 57 Home Health Payment Totals 1 nitet restore ee Ree re ede ed bo gebe a aiaee Te Red eda 58 ANSL Reason Code Inquity orte E E E E ORIS A EEEE 59 ANSI Reason Code Narrative niece dee eiae edet edes Med neo so aaa era a Sa i E ege ENa kA aii 60 Check History Inquiry ceca teet tete edente estre pee LL e Last sa Ee Lama Pese bua ed dede Hip e 62 Diagnosis amp Procedure Code Inquiry ICD10 eese eene nennen 63 SECTION 5 CLAIM ENTRY 65 General EIER TOT PE P En 65 bcunminnnabrr T 65 Electronic UB 04 Claim Entry ri rea thier ertet top Lt rete teintes ie eda Hae in Er dg eo locos 66 UB 04 Clam Entry Page 1 itt neo nee ids neon eaten RUE ee ee SEE Hx EUR R
99. NST CLAIM ENTRY HIC TOB LOC PROVIDER MSP ADDITIONAL INSURER INFORMATION 1ST INSURERS ADDRESS 1ST INSURERS ADDRESS CITY 2ND INSURERS ADDRESS 2ND INSURERS ADDRESS CITY PAYMENT DATA DEDUCTIBLE CROSSOVER IND PARTNER ID PAID DATE PROVIDER PAYMENT PAID BY PATIENT REIMB RATE RECEIPT DATE PROVIDER INTEREST CHECK EFT NO CHECK EFT ISSUE DATE PAYMENT CODE PRICER DATA DRG OUTLIER AMT TTL BLNDED PAYMT FED SPEC GRAMM RUDMAN ORIG REIMBURSEMENT AMT NET INL TECH PROV DAYS TECH PROV CHARGES OTHER INS ID CLINIC CODE PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF9 UPDT ENTER CONTINUE Figure 48 UB 04 Claim Entry Page 6 UB 04 Field Name Ref Description HIC 60 The beneficiary s Medicare Health Insurance Claim number Palmetto GBA Page 96 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system PROVIDER a This field displays the provider identification number INSURER S 58 A Enter the address of the insurance company that corresponds to the line on ADDRESS 1 B C which Medicare payer information is reporte
100. Ne CMS PALMETTO GBA A CELERIAN GROUP COMPANY A CMS Medicare Administrative Contractor Direct Data Entry DDE User s Manual CPT onl ight 2012 American Medical A jation only copyrig p pice A ical Association S e pt e m b e r 2 01 5 DDE User s Manual Table of Contents TABLE OF CONTENTS SECTION 1 INTRODUCTION 1 Provider Contact Center Numbers eese eene nennen nee rennen erinnerte nenne 1 Keyboard esemes Ps 1 Keyboard Function Keys T neea ya cui suit uie ETEEN EAEE EEEO pie EEEa 2 Status Location Codes etes teen tc p ia rae oda ae a e a R E Slo eade oaa 2 Document Control Number DCN sssesssesessseseeee eene enne nne nenn trit ne rennen nennen nennen 3 SECTION 2 CONNECTION INSTRUCTIONS 5 Conmection Proced t S p x oor E EE EEEE ERENER E NEEESE 5 Pinal Connectivity nstructiOns eiie teet rettet ot a ea ene ee en du go ee EENKEER NESER 6 Sign Off uic E 7 Changing Pass Words sreci irr EXER EN e N onsen fase ERR ERN ESSE E MEER ARS E E Ee XR PAYY MESS CERE RENS ERE MERE Cere 7 SECTION 3 MAIN MENU 9 SECTION 4 CLAIM INQUIRY 10 Bene hi Crary O Pi ssctsce 2s age ieee ech a EERE N EEEE EEE NE E E E E E EEEE 10 Beneficiaty C WE SCreens erectis eerte ia e tei KEENE EEEREN E EENE 11 Iuestusi viti 3m I t 28 DRG PPS Inquiry Screen cM 28 Claims Summary lng uiry 2 c fotatot ciet et des Dio EE IR aa E aN SEENE AAA ER quoPaces ESE
101. OASIS Outcome Assessment Information Set of the patient This field is comprised of a 18 digit alpha numeric code that is produced by the Grouper software based on input to the OASIS as follows Positions 1 2 M0030 Start of care date 2 digit number for the year Positions 3 4 M0030 Start of care date alpha characters derived from MM DD code ex 09 01 JK Positions 5 6 M0090 Date assessment completed 2 digit number for the year Positions 7 8 M0090 Date assessment completed alpha characters derived from the MM DD ex 01 01 AA Position 9 M0100 Reason for assessment currently being completed numeric Position 10 M0110 Episode timing numeric based on the actual episode ex episode 1 1 Position 11 Clinical severity points under equation 1 alpha code Position 12 Functional severity points under equation 1 alpha code Position 13 Clinical severity points under equation 2 alpha code Position 14 Functional severity points under equation 2 alpha code Position 15 Clinical severity points under equation 3 alpha code Position 16 Functional severity points under equation 3 alpha code Position 17 Clinical severity points under equation 4 alpha code Position 18 Functional severity points under equation 4 alpha code This field is also used to identify a Centers for Excellence or Provider Partnership Demonstration for NOA Type of Bill 1 1A an
102. Page 119 September 2015 Section 7 Online Reports DDE User s Manual Report View Inquiry MAP1661 Scroll Left View Field descriptions are provided in the table following Figure 64 JM MAC VA WV UAT 11003 REPORT VIEW INQUIRY REPORT 316 FREQUENCY W SCROLL L PAGE 000001 SEARCH ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT i 2 21 B Figure 63 316 Errors on Initial Bills Scroll Left View Report View Inquiry MAP1661 Scroll Right View Field descriptions are provided in the table following Figure 64 JM MAC VA WV UAT 11003 REPORT VIEW INQUIRY REPORT 316 FREQUENCY W SCROLL R PAGE 000001 SEARCH ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF10 LEFT D 3 21 B Figure 64 316 Errors on Initial Bills Scroll Right View Scroll Left View REPORT The unique number assigned to the Summary of Pending Claims Other report FREQUENCY The frequency under which the report is run Valid values are D Daily W Weekly or M Monthly Palmetto GBA Page 120 September 2015 Section 7 Online Reports DDE User s Manual Field Name Description SCROLL Indicates which side of the report you are viewing Scroll L is the left side of the report and Scroll R is the right side Press the F11 and F10 keys to move right and left KEY The provider number PAGE The specific page you are vie
103. QA screen are provided in the table following Figure 78 CWF INQUIRY REPLY BEHAVIORAL SERVICES PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 78 CWF Part A Inquiry Reply Screen Page 13 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA ALCOHOL This field identifies the HCPCS code billed for Alcohol abuse screening ABUSE ALCOHOL This field identifies the HCPCS code billed for a face to face behavioral counseling SCREENING for alcohol misuse ADULT This field identifies the HCPCS code billed for the annual depression screening DEPRESSION IBT FOR CVD This field identifies the HCPCS code billed for Intensive Behavioral Therapy IBT OBESITY for Covered CVD Obesity NEXT ELIG Next Eligible Technical Date This field identifies the next date the patient is TECH eligible for the technical component of the screening NEXT ELIG Next Eligible Professional Date This field identifies the next date the patient is PROF eligible for the professional component of the screening Palmetto GBA Page 140 September 2015 Section 8 Healt
104. RM DT 110407 EFF DT STANDARD CODE MA08 NARRATIVE YOU SHOULD ALSO SEND THIS CLAIM TO THE PATIENT S OTHER INSURER WE DID NOT SEND THE CLAIM DATA AS THE OTHER INSURER IS NOT A MEDIGAP PLAN OR YOU DO NOT PARTICIPATE IN MEDICARE PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE Figure 36 ANSI Standard Codes Inquiry Screen Palmetto GBA Page 61 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description MNT This field identifies the last operator who created or revised this record This is a nine eight position alphanumeric field This field also identifies the date the screen was last accessed by the maintenance operator in the MM DD YY format RECORD TYPES This field displays the types of records that can be displayed on the screen ARE RECORD TYPE This field identifies the ANSI Record Type for the standard code that was selected on the previous screen This is a one position alphanumeric field A Appeals C Adjustment Reasons G Groups R Remarks S Claim status T Claim category TERM DT This field identifies the termination date of the ANSI Standard Code deactivation This is a six digit field in MMDDYY format EFF DT This field identifies the effective date of the ANSI Standard Code activation This is a six digit field in MMDDYY format STANDARD This field identifies the standard code within the above record type that is added CODE This is a five
105. ROV1 PERIOD 016 OWNER CHANGE 016 PERIOD 015 OWNER CHANGE 015 INTER 1 DOEBA DATE DOLBA DATE DAYS USED START DATE2 PROV2 INTER2 REVOCATION IND PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 67 CWF Part A Inquiry Reply Screen Page 2 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code PAP PAP Risk Indicator Valid values are 1 Yes 2 No PAP DATE Date PAP performed MAM Mammo Risk Indicator Valid values are 1 Yes 2 No TECH PROF Mammography Technical Professional Component Date The date the technician professional claims were presented for x rays used for mammography screening IMMUNO Indicates Medicare transplant surgery coverage available to the beneficiary Valid TRANSPLANT values are DATA COV IND 1 Space No Coverage 2 Transplant Coverage Palmetto GBA September 2015 Page 128 Section 8 Health Insurance Query DDE User s Manual Field Name Description TRANS IND Transplant Type Indicator Indicates the type of transplant surgery performed on the beneficiary Valid values are 1 Allograft bone marrow transplant from another person 2 Autograft bone marrow transplant from benefi
106. Report 316 050 The Claims Returned to Provider Report lists the claims that are being returned to the provider for correction The claims on the report are in status location T B9997 The main difference between this report and the 201 is that it contains the description of the Reason Code s for the claim being returned 201 The Pending Processed and Returned Claims Report lists claims that are pending claims returned to the provider for correction and claims processed but not necessarily shown as paid on a remittance advice This report will exclude Medicare Choices ESRD Managed Care and plan submitted HMO Encounter claims 316 The Errors on Initial Bills Report is a listing by provider of errors received on new claims claims which were entered into the system for the present cycle From the Online Reports Menu Figure 55 you can select R1 for a summary of reports from which you can select R2 to view a report by entering the report number Figure 57 or R3 to view a credit balance report Figure 58 Palmetto GBA Page 111 September 2015 Section 7 Online Reports DDE User s Manual Online Reports Selection Inquiry R1 MAP1671 Field descriptions are provided in the table following Figure 56 JM MAC SC HHH UAT 11001 ONLINE REPORTS SELECTION INQUIRY REPORT NO SEL REPORT NO FREQUENCY DESCRIPTION PROCESS COMPLETED NO MORE DATA THIS TYPE PLEASE MAKE A SELECTION ENTER NEW KEY DATA OR PRESS PF3 TO EXIT Fig
107. SS location codes PERFORMING CLAIMS INQUIRIES 1 To start the inquiry process enter the beneficiary s Medicare number or leave out the beneficiary s Medicare number and enter any of the following fields Type of bill TOB S LOC Type an S in the first position of the S LOC field to view all the suspended claims Type a P in the first position of the S LOC field to view all the paid processed claims Typea T in the first position of the S LOC field to view claims returned for correction Type an R in the first position of the S LOC field to view all the rejected claims From Date optional field enter a date if you only want to view claims within a certain date range To Date optional field enter a date only if you want to view claims within a certain date range 2 Once the appropriate claim history displays type an S in the SEL field in front of the claim you wish to view 3 Press ENTER to display the DDE electronic claim Refer to Section 5 Claim Entry for illustrations of the UB 04 claim screens and field descriptions Note You may only select one claim at the time VIEWING AN ADDITIONAL DEVELOPMENT REQUEST ADR LETTER An ADR is an additional development request for medical records Palmetto GBA s medical review department uses ADR s to request medical records from providers during the medical review process Do the following to view an
108. T Part B Entitlement Date of entitlement to Part B benefits in MMDDYY format B TRM Part B Termination Indicates date of termination of Part B entitlement when applicable in MMDDYY format Otherwise this field will display all zeros DOD Date of Death If the beneficiary is alive the field will be all zeros LRSV Lifetime Reserve Shows the number of lifetime reserve days remaining LPSY Lifetime Psychiatric Shows the number of psychiatric days remaining DAYS LEFT Full Hospital Days Remaining Indicates the inpatient days remaining to be paid FULL HOSP at full benefits CO HOSP Coinsurance Hospital Days Remaining Indicates the impatient days remaining to be paid at coinsurance benefits FULL SNF Full SNF Days Remaining Number of SNF days remaining to be paid at full benefits CO SNF Coinsurance SNF Days Remaining Indicates the number of SNF days remaining to be paid at coinsurance benefits IP DED Inpatient Deductible Amount of inpatient deductible remaining BLOOD Blood Deductible Number of pints blood deductible remaining DOEBA Date of Earliest Billing Action For this spell of illness DOLBA Date of Latest Billing Action For this spell of illness CURRENT Current Benefit Period applies to the remaining days inpatient and blood deductible DOEBA and DOLBA described above PRIOR Prior Benefit Period applies to the remaining days inpatient and blood dedu
109. TOT CHRG 47 The total charges displayed on this page are the same as that entered on MAP1712 COV CHRG 47 This field identifies the covered charges entered on MAP1712 ANES CF This field identifies the anesthesia conversion factor ANES BV This field identifies the anesthesia base values FQHCADD Federally Qualified Health Care FQHC Add On This field identifies the line level FQHC additional payment amount for a new patient or initial Medicare visit This is a 13 digit alphanumeric field in 999999999 99 format PC TC IND This field identifies the PC TC Indicator that is added to the CORF services Supplemental Fee Schedule HCPC TYPE This field identifies whether the HCPCS originated from the MPFS database files and it paid off the fee rate This is a one position alphanumeric field The value values are M Originated from MPFS database files Did not originate from the MPFS database files NOTE M indicates the claim is considered an MPFS claim and is edited based on the zip code of the provider master address record If it s an M and the plus four flag of the 5 digit zip code record is a 1 then the provider master address must contain a valid 4 digit extension The carrier and locality on the provider master address record and the carrier and locality of the zip code file must match Otherwise the claim receives an edit Palmetto GBA Page 75 September 2015 Section 5 Claim Entry Field
110. TYPE DATE REAS DATE DATE ST LOC ST LOC LOC IND HD CPY A B NB ADR PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 29 Reason Codes Inquiry Screen Example 1 Field Name Description MNT Identifies the last date the reason code was updated PLAN IND Plan Indicator All FISS shared maintenance customers will be 1 the value for FISS shared processing customers will be determined at a later date REAS CODE Identifies a specific condition detected during the processing of a record NARR TYPE The type of reason code narrative provided This field defaults to E for external message EFF DATE Identifies the effective date for the reason code or condition Palmetto GBA Page 52 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description MSN REAS The Medicare Summary Notice reason code is used when MSN s requiring BDL messages are produced The reason code on the claim will be tied to a specific MSN reason code on the reason code file that will point to a specific MSN message on the ACS MSN file EFF DATE Effective date for the MSN reason code TERM DATE Termination date for the MSN reason code EMC ST LOC Identifies the status and location to be set on an automated claim when it encounters the condition for a particular reason code If it is the same for both hard copy and EMC claims the data will only appear in the hard copy category and the system will default t
111. Therapy The amount applied to the physical therapy services provided in an outpatient setting OT APL Occupational Therapy The amount applied to the occupational therapy services provided in an outpatient setting Palmetto GBA September 2015 Page 149 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 2 Field definitions and completion requirements are provided in the table following Figure 84 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 84 CWF Part A Inquiry Reply Screen Page 2 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code SPELL NUM Spell of Illness Number This number reflects the current home health spell of illness QUALIFYING Qualifying Stay Indicator This is a numeric field used to identify a qualifying A B IND split hospitalization Valid values are 0 No 1 2 Yes PART A VISITS The number of Part A visits remaining in the episode of care Medicare Part A pays for REMAINING the first 100 visits if a patient has a qualifying hospital stay and if a patient is admitted to home health within 14 days of discharge Medicare Part B pays for the remaining visits In addition Medicare P
112. Through Date This field identifies the ending date of service for the period included on the claim in MMDDYY format QUARTER This field identifies the quarter ending date in CCYYMM format ENDING 050 Report Claims Returned to Provider The Claims Returned to Provider Report lists the claims that are being returned to the Provider for correction The claims on the report are in status location T B9997 It is primarily used by providers who are not on DDE to identify the Reason Code s for the returned claims This report includes the Reason Code s by number and narrative Figures 59 and 60 Palmetto GBA Page 114 September 2015 Section 7 Online Reports DDE User s Manual Report View Inquiry MAP1661 Scroll Left View Field descriptions are provided in the table following Figure 60 MAP1661 JM A B MAC SC HHH 11001 ACPFA391 09 01 15 REPORT VIEW INQUIRY C201533P 14 55 47 REPORT FREQUENCY SCROLL KEY PAGE SEARCH REPORT 050 SUBMITTER MEDICARE PART A 11 CYCLE DATE 08 31 15 CLAIMS RETURNED TO PRO PROVIDER FOR CYCLE DATE 08 31 FOR PROVIDER HIC CERT SSNO PCN DCN TYPE BILL PROV NPI NAME 30727 THE PRINCIPAL DIAGNOSIS CODE ON THE CLAIM IS EQUAL DIAGNOSIS CODE TOTAL RETURNED CLAIMS 1 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 59 050 Claims Returned to Provider Scroll Left View Report View Inquiry MAP1661 Scroll Right View Field d
113. UNT SUMMARY 56 REVENUE CODES HOME HEALTH PYMT TOTALS 67 HCPC CODES ANSI REASON CODES 68 DX PROC CODES ICD 9 CHECK HISTORY FI ADJUSTMENT REASON CODES DX PROC CODES ICD 10 1B REASON CODES ENTER MENU SELECTION I PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 5 Inquiry Menu The screens displayed from each of the options on the inquiry menu screen will display the SC field on the upper left side of the screen The SC field is defined as the scroll function which is a two digit field in which you can enter the number from the inquiry menu screen that you want to access Using the scroll function eliminates the need to exit to the menu each time you are ready to proceed to the next inquiry screen For example from any of the Beneficiary CWF screens you can enter 10 in the SC field to move to the DRG Pricer Grouper screen instead of hitting the F3 key to return to the inquiry menu to get to the DRG Pricer Grouper screen Beneficiary CWF Select option 10 from the Inquiry Menu to access the Beneficiary CWF screens These screens display current Medicare Part A and Part B entitlement and utilization information about a specific beneficiary There are several pages screens of eligibility information Screen MAP1751 Patient eligibility information in the FISS Screen 2 MAP1752 Patient eligibility information in the FISS Screen 3 MAPI75A Patient eligibility information in the FISS Screen 4 MAP17
114. Voluntary Reporting Contractor 11106 All other reasons for non payment Payment requested Q MSP Voluntary Agreements Contractor 88888 Q Employer Voluntary Reporting Contractor 11105 UzAcTrIOTTI OU Palmetto GBA Page 81 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description R Spell of illness benefits refused certification refused failure to submit evidence Provider responsible for not filing timely or Waiver of Liability T MSP Initial Enrollment Questionnaire Contractor 99999 or 11101 U MSP HMO Cell Rate Adjustment Contractor 55555 U HMO Rate Cell Contractor 11103 V MSP Litigation Settlement Contractor 33333 V Litigation Settlement Contractor 11104 W Workers Compensation X MSP cost avoided Y IRS SSA Data Match Project MSP Cost Avoided Contractor 77777 Y IRS SSA CMS Data Match Project Cost Avoided Contractor 11102 Z System set for type of bills 322 and 332 containing dates of service 10 01 00 or greater and submitted as an MSP primary claim This code allows the FISS to process the claim to CWF and allows CWF to accept the claim as billed 00 COB Contractor Contractor 11100 12 Blue Cross Blue Shield Voluntary Agreements Contractor 11112 13 Office of Personnel Management OPM Data Match Contractor 11113 14 Workers Compensation WC Data Match Contractor 11114 GENER Instructs the s
115. Y format SERVICE TYPE OF BILL Enter the first two digits of the type of bill being submitted as a roster bill Valid values are 22 Skilled Nursing Facility SNF Inpatient Part B 23 SNF Outpatient 34 Home Health Part B Only 72 Independent or Hospital Based Renal Dialysis Facility 75 Comprehensive Outpatient Rehabilitation Facility 85 Critical Access Hospital The system will autofill the third digit of the bill type when the roster is transmitted NPI This field identifies the National Provider Identifier number TAXO CD This field identifies a collection of unique alpha numeric codes The code set is structured into here distinct levels including Provider Type Classification and Area of Specialization FAC ZIP This field identifies the provider or subpart nine digit ZIP code REVENUE Enter the specific accommodation or service that was billed on the claim This CODE should be done by line item Valid values are 0636 or 0770 HCPC HCPCS applicable to ancillary services being billed CHARGES PER Enter the charges per revenue code being charged to the beneficiary BENEFICIARY After all the above information is entered press the Enter key The cursor will automatically move to the top of the page Use the Tab key to move to the HIC field and enter the information listed below Patient Information HIC NUMBER The health insurance claim number assigned when
116. arge the beneficiary LTR DAYS The number of lifetime reserve days This 2 digit field may be left blank PAT LIAB cover any coinsurance days or non covered days or charges The Patient Liability Due identifies the dollar amount owed by the beneficiary to After the DRG has been assigned by the system and the PPS payment has been determined the following information will be displayed on the screen under RETURNED FROM GROUPER or RETURNED FROM PRICER GROUPER The program identification number for the Grouper program used VERSION D R G The DRG code assigned by the CMS grouper program using specific data from the claim such as length of stay covered days sex age diagnosis and procedure codes discharge data and total charges MAJOR DIAG Identifies the category in which the DRG resides Valid values are CAT 01 Diseases and Disorders of the Nervous System 02 Diseases and Disorders of the Eye 03 Diseases and Disorders of the Ear Nose Mouth and Throat 04 Diseases and Disorders of the Respiratory System 05 Diseases and Disorders of the Circulatory System 06 Diseases and Disorders of the Digestive System 07 Diseases and Disorders of the Hepatobiliary System and Pancreas 08 Diseases and Disorders of the Musculoskeletal System and Connective Tissue 09 Diseases and Disorders of the Skin Subcutaneous Tissue and Breast 10 Endocrine Nutritional and Metabolic Diseases and Disorders 11
117. art B pays for all visits if there is no qualifying hospital stay the patient must have Medicare Part B for Part B to reimburse for the services If a beneficiary has Medicare Part A only then Part A will pay for all of their services EARLIEST The earliest date submitted for the spell of illness BILLING LATEST BILLING The latest date submitted for the spell of illness PARTB VISITS The number of visits in the episode of care that were reimbursed by Medicare Part B APPLIED Palmetto GBA Page 150 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 3 Field definitions and completion requirements are provided in the table following Figure 85 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 85 CWF Part A Inquiry Reply Screen Page 3 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code START DATE Start Date Shows the start date of the home health episode END DATE End Date Indicates end date of the home health episode INTER NUM Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA PROV NUM Provider Number The provider number of the home
118. at require further investigation Medicare contractor reviews these claims makes corrections and resubmits them to CWF e Recycled claims which recycle automatically back to CWF The FISS status location definitions are Palmetto GBA Page 122 September 2015 Section 8 Health Insurance Query DDE User s Manual S B90 0 1 transmission S B90 1 2 transmission S B90 2 additional transmissions CWF Host Sites The Centers for Medicare amp Medicaid Services maintains centralized files on each Medicare beneficiary with minimal eligibility and utilization data Contractors query this file to process claims CWF disperses the beneficiary files into nine regional host sites GW Great Western GL Great Lakes MA Mid Atlantic SE Southeast Illinois Indiana Alabama Idaho North Dakota Michigan Maryland Mississippi lowa Oregon Minnesota Ohio North Carolina Kansas South Dakota Wisconsin Virginia South Carolina Missouri Utah West Virginia Tennessee Montana Washington Nebraska Wyoming PA Pacific SO South KS Keystone NE Northeast SW Southwest Alaska Florida Delaware Connecticut Arkansas Arizona Georgia New Jersey Maine Colorado California New York Massachusetts Louisiana Hawaii Pennsylvania New Hampshire New Mexico Nevada Rhode Island Oklahoma Vermont Texas HIQA Inquiry Screen Once you have successfully logged onto the DDE system from the blank screen type HIQA to access the inquir
119. ate of last billing action DAYS USED _ Lists the number of days used per benefit period START DATE2 Lists second start date if a beneficiary elects to change hospices during a benefit period PROV2 Indicates the Second provider to bill hospice claims when the beneficiary chooses to change providers during a benefit period INTER2 Second Intermediary Number Indicator as to the Medicare contractor that is processing the hospice claim if the beneficiary elects to change hospices during a benefit period that submits claims to a different contractor REVOCATION Revocation Indicator Indicates if a beneficiary has revoked hospice benefits for IND the period Valid values are 0 Beneficiary has not revoked hospice benefits 1 Beneficiary has revoked hospice benefits 2 Beneficiary has revoked hospice benefits record was manually updated by CWF at the request of the Medicare contractor HIQA Page 4 Field descriptions for Page 4 of the HIQA screen are provided in the table following Figure 69 INQUIRY REPLY Figure 69 CWF Part A Inquiry Reply Screen Page 4 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code SPELL NUM S
120. ates electronic fund transfer DATE The date when the payments were issued AMOUNT The dollar amount of the last three payments issued to the provider Diagnosis amp Procedure Code Inquiry ICD10 Select option 1B from the Inquiry Menu to access the ICD 10 CM Code Inquiry screen This screen displays an electronic description for the ICD 10 CM Codebook This screen should be used as reference for ICD 10 CM code s to identify a specific diagnosis code or inpatient surgical procedure code for a related bill An effective date will be listed below each code and if applicable a termination date is also provided To inquire about an ICD 10 CM diagnosis code type a D in the DIAG PROC field then tab to the STARTING ICD 10 CODE field and type in the code To inquire about an ICD 10 CM procedure code type the letter P in the DIAG PROC field and tab to the STARTING ICD 10 CODE field and type in the code Palmetto GBA Page 63 September 2015 Section 4 Claim Inquiry DDE User s Manual ICD 10 CM Code Inquiry Screen MAP1C31 Field descriptions are provided in the table following Figure 38 MAP1C31 JM MAC SC HHH UAT 11001 SC ICD 10 CM CODE INQUIRY DIAG PROC STARTING ICD 10 CODE D P ICD 10 CODE DESCRIPTION EFFECTIVE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 38 ICD 10 CM Code Inquiry Screen Field Name Description DIAG PROC This field identifies whether or not this is an ICD 10 diagno
121. ays for inpatient and SNF types of bills 11X 41X 18X 21X 28X and 51X on the cost report The system calculates this field and inserts the applicable data NON COST RPT Identifies the number of Non Cost Report Days not claimable as Medicare DAYS patient days for inpatient and SNF types of bills 11n 18n 21n 28n 41n and 51n on the cost report DIAGNOSIS 67 A Used to enter the full Diagnosis Codes for the principal diagnosis code and CODE 01 09 Q up to eight additional conditions coexisting at the time of admission which developed subsequently and which had an effect upon the treatment given or the length of stay END OF POA 67 This field identifies the last character of the Present On Admission POA INDICATOR indicator effective with discharges on or after 01 01 08 The valid values are Z The end of POA indicators for principal and if applicable other diagnosis X The end of POA indicators for principal and if applicable other diagnosis in special processing situations that may be identified by CMS in the future Not acute care POA s do not apply Palmetto GBA Page 90 September 2015 Section 5 Claim Entry DDE User s Manual R UB 04 n Field Name X Ref Description ADMITTING 69 In the Admitting Diagnosis field for inpatients enter the full code for the DIAGNOSIS principal diagnosis relating to condition established after study to be chiefly re
122. c 62 Invalid number of covered days e g more than approved length of stay non numeric or lifetime reserve days greater than covered days 63 Review code of 00 or 03 and bill is cost outlier candidate 64 Disproportionate share percentage and bed size conflict on Provider specific file 98 Cannot process bill older than 10 01 87 PAY METHOD Identifies the method of payment i e OPPS LAB fee schedule etc returned from OCE Valid values include 1 Paid standard OPPS amount service indicators S T V X or P 2 Services not paid under OPPS service indicator A or no HCPCS code and certain revenue codes 3 Not paid service indicators C or E 4 Acquisition cost paid service indicator F 5 Designated current drug or biological payment adjustment service indicator G 6 Designated new device payment adjustment service indicator H 7 Designated new drug or new biological payment adjustment service indicator J 8 Not used at present 9 No separate payment included in line items with APCS service indicator N or no HCPCS code and certain revenue codes or HCPCS codes Q0082 activity therapy G0129 occupational therapy or G0172 partial hospitalization program services IDE NDC UPC This field contains IDE NDC or UPC IDE Investigational Device Exemption NDC Reserved for future use UPC Reserved for future use
123. ciary H Heart transplant K Kidney transplant L Liver transplant DISCH DATE Discharge Date The date that the beneficiary was discharged from a hospital stay during which the indicated transplant occurred HOSPICE DATA Indicates if a beneficiary has or had elected the Medicare hospice benefit START DATE 1 The elected start date of a beneficiary s hospice benefit period TERM DATE 1 The termination of the first hospice benefit period May be listed as the end of the benefits for the hospice period indicated or the revocation of hospice benefits PROV1 First Provider First provider the beneficiary has elected for hospice benefits This is the assigned Medicare provider number INTER1 First Intermediary Number Indicator as to the Medicare contractor that is processing the Hospice claim DOEBA Date of earliest billing action DOLBA Date of last billing action DAYS USED Lists the number of days used per benefit period Period 1 2 1 90 days Period 2 1 90 days Unlimited number of subsequent 60 day benefit periods START DATE2 Lists second start date if a beneficiary elects to change hospices during a benefit period PROV2 Indicates the Second provider to bill hospice claims when the beneficiary chooses to change providers during a benefit period INTER2 Second Intermediary Number Indicator as to the Medicare contractor that is processing the hospice claim if the beneficiary elects t
124. ciary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA Bone Density Services HCPCS This field identifies the HCPCS codes billed for the bone density services NEXT This field reflects the next eligible date for the technical component of the bone ELIGIBLE density services TECH DATE NEXT This field reflects the next eligible date for the professional component of the bone ELIGIBLE density services PROF DATE RULE This field identifies the allowable HCPCS codes and how often for the bone density services Palmetto GBA Page 164 September 2015 Appendix Acronyms 00 I DDE User s Manual APPENDIX ACRONYMS Acronym Description HIPPS Health Insurance Prospective ACS Automated Correspondence System Payment System the coding ADR Additional Development Request system for home health claims ADJ Adjustment HMO Health Maintenance Organization APC Ambulatory Payment Classification HPSA Health Professional Shortage Area ASC Ambulat
125. ck was issued or the date the electronic funds transfer ISSUE DATE occurred PAYMENT Displays the payment method of the check or electronic funds transfer Valid values CODE are ACH Automated Clearing House or Electronic Funds Transfer CHK Check NON Non payment data Pricer Data DRG The Diagnostic Related Grouping Code assigned by the pricer s calculation OUTLIER AMT The Outlier Amount qualified for outlier reimbursement TTL BLNDED Not utilized in DDE PAYMENT FED SPEC Not utilized in DDE Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual Field Name Description GRAMM The Gramm Rudman Original Reimbursement Amount RUDMAN ORIG REIM AMT NET INL Not utilized in DDE TECH PROV Technical Provider Days The number of days for which the provider is liable DAYS TECH PROV Technical Provider Charges The dollar amount for which the provider is liable CHARGES OTHERINS ID Not utilized in DDE CLINIC CODE Not utilized in DDE Roster Bill Entry To access the Roster Bill Entry page open the Claim and Attachments Entry Menu select option 02 from the Main Menu and then select option 87 The DDE Roster Bill page Figure 49 will display This page allows providers to enter their pneumococcal pneumonia and flu shots in a roster bill format After typing roster bill information press F9 to transmit the claim When completing the roster bill providers should observe the foll
126. codes in the Record Type field and the specific code e g 45 To obtain the information for a specific ANSI reason code select A enter the code and press ENTER or you can leave the Record Type field blank press ENTER and a list of ANSI reason codes will display Palmetto GBA Page 59 September 2015 Section 4 Claim Inquiry DDE User s Manual ANSI Reason Code Inquiry Screen MAP1581 Field descriptions are provided in the table following Figure 34 JM MAC SC HHH UAT 11001 SC ANSI STANDARD CODES SEL INQUIRY RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE TERM DT NARRATIVE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 34 ANSI Related Reason Codes Inquiry Selection Screen Field Name Description RECORD TYPE Identifies the ANSI record type for the standard code for inquiry or updating Enter the value for the type of code you want to view Valid values are C Claim adjustment reason G Group codes R Remittance Advice Remark A ANSI Reason Code T Claim category S Claim Status STANDARD CODE The standard code within the above record type for inquiry or updating Enter the code needed or press Enter and the entire list of codes for the record type selected above will be displayed If both record and standard codes are present the information for that code will be displayed Otherwise all ANSI codes will be disp
127. coinsurance wage adjusted and reduced amounts calculated within the MSPPAY module and apportioned upon return from the MSPPAY module Not displayed on new claims MSP claims cannot be submitted or corrected in DDE MSP This field identifies additional Medicare Secondary Payer deductible blood and cash and coinsurance wage adjusted and reduced amounts calculated within the MSPPAY module and apportioned upon return from the MSPPAY module Not displayed on new claims MSP claims cannot be submitted or corrected in DDE Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual UB 04 X Ref ANSI This 2 character Group Code and 3 character Reason Adjustment Code is used to send ANSI information to the Financial System for reporting on the remittance advice for the ESRD Reduction Psychiatric Coinsurance Hemophilia Blood Clotting Factor PAY HCPC APC HCPC Ambulatory Patient Classification Code Identifies the APC CD Payment Ambulatory Patient Classification Code group number by line item Payment for services under the OPPS is calculated based on grouping outpatient services into APC groups The payment rate and coinsurance amount calculated for an APC apply to all of the services within the APC Both APC codes appear on the claims file but only one appears on the screen If their values are different this indicates a partial hospitalization item In this case the payment APC code is displayed
128. ctible DOEBA and DOLBA described above PART B YR Most Recent Part B Year From the applicable date input field DED TBM Deductible To Be Met Amount of the Part B cash deductible remaining to be met for the current year BLD Blood Part B blood deductible pints remaining to be met YR Year Next most recent Part B year DED TBM Deductible to be Met DI Data Indicators A State Buy In 0 Does not apply 1 State buy in involved B Alien Indicator 0 Does not apply 1 Alien nonpayment provision may apply C Psychiatric Pre entitlement Palmetto GBA September 2015 Page 126 Section 8 Health Insurance Query DDE User s Manual Field Name Description 1 Psychiatric pre entitlement reduction applied D Reason for entitlement 0 Normal 1 Disability 2 End Stage Renal Disease ESRD 3 Has or had ESRD but has current DIB 4 Old age but has or had ESRD 8 Has or had ESRD and is covered under premium Part A 9 Covered under premium Part A FULL NAME Beneficiary s full name PER Medicare Advantage HMO Period of Enrollment Code which indicates that the individual has had 1 2 or 3 periods of enrollment in an HMO PLAN TYP Medicare Advantage HMO Plan Type The type of plan the beneficiary has CURR ID Medicare Advantage HMO Identification Code Valid values are 1 Position H 2 amp 3 Position state code 4 amp 5 Position HMO number within the state OPT Me
129. d 11D The valid values are Palmetto GBA Page 95 September 2015 Section 5 Claim Entry DDE User s Manual Field Name eae Description 09 Discharge from agency 10 Discharge from agency no visits completed after start resumption of care assessment 07 Centers for Excellence 08 Providers Partnership Demonstration Note This field is also used to report the Unique Tracking Number UTN associated with the Medicare Payer iteration For bill types other than 32X or 33X report the UTN in positions 1 14 For 32X bill types report the 14 position UTN immediately following the 18 position OASIS Treatment Authorization Number The valid format of the UTN is Positions 1 2 MAC Jurisdiction alpha numeric Position 3 A Part A program or H for Home Health Hospice Program Positions 4 14 Numeric UB 04 CLAIM ENTRY PAGE 6 The following information can be found on Page 6 of the UB 04 Claim Entry screen Figure 48 Medicare Secondary Payer MSP address Payment data coinsurance deductible etc Pricer data DRG etc Note MSP claims cannot be submitted or corrected in DDE Providers may view data on this screen through the claims inquiry screen but will not enter information on this page INST Claim Entry Screen Page 6 MAP1716 Field descriptions are provided in the tables following Figure 48 MAP1716 PAGE JM MAC SC HHH UAT 11001 SC I
130. d STATUS EMC Electronic Media Claim Status Code This field identifies the EMC status of the claim that is returned on a 277 claim response This is a four digit alphanumeric field HC Hard Copy Claim Status This field identifies the Hard Copy status of the claim that is returned on a 277 claim response This is a four digit alphanumeric field OSC Repository Inquiry The purpose of the OSC Occurrence Span Code Repository Inquiry screen is to display the occurrence span code repository record Up to three occurrences can display on a page Specific occurrences can be displayed by typing a page number in the PG field at the upper left hand corner of the screen Select Option 1A from the inquiry screen to access this screen OSC Repository Inquiry Screen MAP11A1 Field descriptions are in the table below Figure 31 PG JM MAC SC HHH UAT 11001 SC DDE OSC REPOSITORY INQUIRY PROVIDER HIC ADMIT DATE DOCUMENT CONTROL NUMBER OSC FROM DATE TO DATE OSC FROM DATE TO DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 31 DDE OSC Repository Inquiry Field Name Description PROVIDER This field displays the provider identification number Palmetto GBA Page 56 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description HIC This field displays the beneficiary s Medicare number as shown on the Medicare card ADMIT DATE This field identifies the pat
131. d FL58 A B C AND2 CITY 1 AND2 58 A Enter the specific city of the insurance company B C ST 1 AND2 58 A Enter the specific state of the insurance company B C ZIP 1 AND2 58 A Enter the specific zip code of the insurance company B C Payment Data This information is available for viewing in Detail Claim Inquiry Option 12 immediately after the claim is updated entered in DDE Field Name Description Payment Data DEDUCTIBLE Amount applied to the beneficiary s deductible payment COIN Amount applied to the beneficiary s co insurance payment CROSSOVER The Crossover Indicator identifies the Medicare payer on the claim for payment IND evaluation of claims crossed over to their insurers to coordinate benefits Valid values are 1 Primary 2 Secondary 3 Tertiary PARTNER ID Identifies the Trading Partner number PAID DATE This is the actual date that claim was processed for payment consideration PROVIDER This is the actual amount that provider was reimbursed for services PAYMENT PAID BY This is the actual amount reimbursed to beneficiary Not utilized in DDE PATIENT REIMB RATE Provider s specific reimbursement rate PPS RECEIPT DATE Date claim was first received in the FISS system PROVIDER Interest paid to the provider INTEREST CHECK EFT Displays the identification number of the check or electronic funds transfers NO CHECK EFT Displays the date the che
132. d by CMS AMT to the MACs by provider entitled to an uncompensated care payment amount add on The MACs enter the amount for each Federal Fiscal year begin date 10 01 based on published information This is an eleven digit field in 9999999 99 format BUNDLE ADJ This field identifies the adjustment amount for hospitals participating in the AMT Bundled Payments for Care Improvement Initiative BPCI Model 1 demo code 61 This is an eleven digit field in 9999999 99 format VAL PURC ADJ This field identifies the adjustment amount for hospitals participating in the Value AMT Based Purchase Program This is an eleven digit field in 9999999 99 format READMIS ADJ This field identifies the reduction adjustment for those hospitals participating in the AMT Hospital Readmissions Reduction program This is an eleven digit field in 9999999 99 format PPS STNDRD This field identifies the final standardized amount This value is returned from the VALUE IPPS Pricer for claims that meet the criteria identified in specification SO580000 This is an eleven digit field in 9999999 99 format PPS HAC PAY This field identifies the Hospital Acquired Condition HAC payment reduction AMT amount This is an eleven digit field in 9999999 99 format PPS FLX7 AMT This field is reserved for future use This is an eleven digit field in 9999999 99 format EHR PAY ADJ AMT This field identifies the reduction adjustment amount for hospitals n
133. d for Medicare Secondary Payer MSP involvement and has its final reimbursement including interest when applicable before it is sent High Speed bulk data transfer transmits the Medicare contractor paid claim to the host for approval Prior to SEND the Medicare contractor converts adjudicated claims from in house format to CWF format This is known as the best shot approach for bill payment Claims awaiting CWF transmission reside in status location S B9000 Part A Response Process Palmetto GBA maintains a holding file containing claims awaiting an initial CWF response S B9099 No manual transaction can be made against these claims Claims cannot be finally adjudicated until a definitive response is received from CWF unless a manual function instructs the system to process the claim without being transferred to CWF Responses aid in processing and proper adjudication of Medicare claims The responses Palmetto GBA receives from the CWF are e CWF Edit Error codes that tell us a CWF response is ready to be worked a 5 digit code appears in the lower left corner of the UB04 claim screen e ACWE Disposition Code a 2 digit category or status of claim that indicates Claim is approved Claim is rejected Claims will be retrieved from history e Alert codes CWF requests for investigation of overlapping benefits and eligibility status e Approved claims Medicare contractor produced provider check and remittance advice e Rejected claims th
134. ded In Treatment Plan 100015 2 Services Not Included In Plan Of Care 100016 No Physician Certification E G Home Health 100017 Incomplete Physician Order 100018 2 No Individual Treatment Plan 100019 Other MR INDICATOR Medical Review Indicator This field identifies whether or not the service received complex manual medical review This is a one position alphanumeric field The valid values are The services did not receive manual medical review default value Y Medical records received This service received complex manual medical review N Medical records were not received This service received routine manual medical review PCA INDICATOR Progressive Correction Action PCA Indicator This field identifies the PCA indicator This is a one position alphanumeric field The valid values are The Medical Policy Parameter is not PCA related and is not included in the PCA transfer files Y The Medical Policy Parameter is PCA related and is included in the PCA transfer files N The Medical Policy Parameter is not PCA related and is not included in the PCA transfer files LMRP NCD ID Local Medical Review Policy LMRP and or National Coverage Determination NCD Identification Number This field identifies the LMRP NCD identification numbers which are assigned to the FMR reason code for reporting on the beneficiaries Medicare Summary Notice This is an eleven position alphanumeric field with
135. denied for medical necessity reasons no adjustments can be submitted If the claim was partially denied for medical necessity a provider may adjust the claim but may only change delete add line items that were not denied To access the claim and make the adjustment 1 Select the option on the Claim and Attachments Correction Menu for the type of claim to be adjusted and press ENTER End Stage Renal Disease ESRD Comprehensive Outpatient Rehab Facilities CORF and Outpatient Rehab Facilities ORF will need to select the outpatient option and then change the TOB 2 Enter the HIC number and the FROM and TO dates of service and then press ENTER The system will automatically default the TOB frequency to an XX7 The HIC number field is now protected and may no longer be changed Palmetto GBA Page 108 September 2015 Section 6 Claim Correction DDE User s Manual 3 Indicate why you are adjusting the claim by entering the claim change condition code on Page 01 of the claim and a valid Adjustment Reason Code on Page 03 Valid Adjustment Reason Codes can be found typing 16 in the SC field in the upper left hand corner of the screen and pressing ENTER Press ENTER again to view the entire list of valid codes and descriptions If you wish to view the description of a code you want to use enter the code in the Reason Code field 4 Give a short explanation of the reason for the adjustment in the remarks section on Page 04
136. dical review reasons specific to claim level The system determines this by a C in the claim line indicator on the reason code file The medical review reasons must contain a 5 in the first position OCE MED REV The OCE Medical Review field displays the edit returned from the OPPS RSNS version of OCE Valid values include 11 Non covered service submitted for review condition code 20 12 Questionable covered service 30 Insufficient services on day of partialization 31 Partial hospitalization on same day as electro convulsive therapy or type T procedure 32 Partial hospitalization claim spans 3 or less days with insufficient services or electro convulsive therapy or significant procedure on at least one of the days 33 Partial hospitalization claim spans more than 3 days with insufficient number of days having mental health services UNTITLED This Claim Line Number field identifies the line number of the revenue code The line number is located above the revenue code on this map To move to another revenue code enter the new line number and press ENTER REV 47 Identifies the Revenue Code for a specific accommodation or service that was billed on the claim This information was entered on MAP1712 Valid values are 01 to 9999 To move to the next Revenue Code with a line level reason code position the cursor in the page number field and press F2 Palmetto GBA Page 84 September 2015 Section 5 Cla
137. dicare Advantage HMO Option Code Describes the beneficiary s relationship with the HMO Valid values are 10r2 HMO to process bills only for directly provided services and for service from providers with whom the HMO has effective arrangements Palmetto GBA processes all other bills C HMO to process all bills ENR Medicare Advantage HMO Enrollment Date the date the beneficiary enrolled in the plan TERM HMO Medicare Advantage HMO Termination Date the date the beneficiary disenrolled from the plan PRIOR PLAN Prior Medicare Advantage HMO Plan type displays the prior type of plan the TYP beneficiary was enrolled in PRIOR ID Prior Medicare Advantage HMO Plan ID displays the prior plan ID OPT Prior Medicare Advantage HMO Option Enrollment Code displays the option code from a prior plan ENR Prior Medicare Advantage HMO Enrollment Date date the beneficiary enrolled in prior plan TERM Prior Medicare Advantage HMO Termination Date date the beneficiary disenrolled from a prior plan PART A YR Current Part A impatient stay data BLD Blood Blood deductible pints remaining to be met PT APL Physical Therapy The Part B physical therapy amount remaining for the most recent Medicare Part B benefit year OT APL Occupational Therapy The Medicare Part B occupational therapy amount remaining for the most recent part B benefit year CATASTROPHIC This field identifies
138. digit alphanumeric field NARRATIVE This is the narrative description of the standard code This is an alphanumeric field that will display up to 70 characters with up to five screens Check History Inquiry Select option FP from the Inquiry Menu to access the Check History screen This screen lists Medicare payments for the last three issued checks paid hardcopy or electronically If you are interested in electronic payment contact the EDI Department Press ENTER and the last three checks issued by Medicare will display Note The system will automatically enter your provider number into the PROVIDER PROV field If the facility has multiple provider numbers you will need to change the provider number to inquire or input information TAB to the PROV field and type in the provider number Palmetto GBA Page 62 September 2015 Section 4 Claim Inquiry DDE User s Manual Check History Screen MAP1B01 Field descriptions for the Check History screen are provided in the table following Figure 37 MAP1B01 JM MAC SC HHH UAT 11001 CHECK HISTORY PROV NPI CHECK DATE AMOUNT PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 37 Check History Screen Field Name Description PROV The Medicare assigned provider number NPI The provider s National Provider Identifier NPI number CHECK The last three payments issued to the provider by Medicare Leading zeros indicate a check EFT indic
139. e Refer to UB 04 Manual for valid values STATUS DT The date the patient was discharged in MMDDYY format PROV The provider s Medicare provider number Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description REVIEW CODE Indicates the code used in calculating the standard payment Valid values are 00 Pay with outlier Calculates standard payment and attempts to pay only cost outliers 01 Pay days outlier Calculates standard payment and the day outlier portion of the payment if the covered days exceed the outlier cutoff for DRG 02 Pay cost outlier Calculates the standard payment and the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold if the length of stay exceeds the outlier cutoff no payment is made and a return code of 60 is returned 03 Pay per diem days Calculates a per diem payment based on the standard payment if the covered days are less than the average length of stay for the DRG if the covered days equal or exceed the average length of stay the standard payment is calculated It also calculates the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold 04 Pay average stay only Calculates the standard payment but does not test for days or cost outliers 05 Pay transfer with cost Pays transfer with cost outlier approved 06 Pay transfer no cos
140. e 1 CICS Sign On Screens Em 5 Figure 2 TPX Menu Screen iniit er eee e Ea edlen eder Ph Cere Be Bean epe RU PE Sra Pe CESTA Re Lau 6 Figure 3 The Main Menu Ec M 7 Ligure 4 Th Mati Menu neret ete Hr eee a aa Hee A Ro EEEREN E EE EE 9 Figure 5 Inguiry 10 Figure 6 Be neficiary CWE Screen 1 o ccpcccscaissscgessecsotsedsncessepsctesstagnongesnndsensedestesnuguodesosdgosegeesedeeteesers 11 Figure 7 Beneficiary CWE Screen 2 etse rere tek eto eo iki Igea enge aS eR avo Led aoa Ea e LE duran 12 Figure 8 Beneficiary CWF Screen 3 irnitensee egeo eerie the lee Ree ela ripeto edet ear E EE L o Rueda eo pred era 14 Figure 9 Beneficiary CWF Screen Arrinca a nennen nennen nnne enne enr EE 15 Figure 10 Beneficiary CWF Screen 5 esses ener teen rennen rennen 16 Figure 11 Beneficiary CWF Screen 6 ssesseeseeseeeeeeeeee nennen entente nne tne enn enne 17 Figure 12 Beneficiary CWE Screen 7 eee eere ertet e shed spantyensaessutssussdetey sscgbocseustyeonsessneeeaaseede 20 Figure 13 Beneficiary CWF Screen 8 esee eene ener enne enr enn enne 23 Ligure 14 Beneficiary CWEF Screen 9 bi dere cepe Pepe s ERE Cope LEE ED Fes reae be ege Runden 24 Figure 15 Beneficiary CWF Screen 10 esses eene nnne nennen rennen innen 25 Figure 16 Beneficiary CWF Screen 11 eese enne netten nre enne 2
141. e 139 Figure 78 CWF Part A Inquiry Reply Screen Page 13 ee cescceseceseceseceseceseeeeeeeseeeeneeeaeeeaeeeaaeenaes 140 Figure 79 CWF Part A Inquiry Reply Screen Page 14 sese 141 Figure 80 CWF Part A Inquiry Reply Screen Page 15 sss eee 142 Figure 81 CWF Part A Inquiry Reply Screen Page 16 oie eee eesceseceseceseceeeeeseeeeeeeseeesaeeeaeeeseeeaaeenaes 143 Figure 82 CWF Part A Beneficiary Inquiry Screen eese ener 146 Figure 83 CWF Part A Inquiry Reply Screen Page 1 sse enn 148 Figure 84 CWF Part A Inquiry Reply Screen Page 2 0 0 ee eeessecsseceseceseceeceeeeeeeeeseeeeaeeeaeeeaeeeaaeenaes 150 Figure 85 CWF Part A Inquiry Reply Screen Page 3 sees 151 Figure 86 CWF Part A Inquiry Reply Screen Page 4 sesesssssesseeeeeeeeeee nene 152 Figure 87 CWF Part A Inquiry Reply Screen Page 5 sess 153 Figure 88 CWF Part A Inquiry Reply Screen Page 6 essesesesseseeeeeeeeeenne emen 154 Figure 89 CWF Part A Inquiry Reply Screen Page 7 esee eene eee 154 Figure 90 CWF Part A Inquiry Reply Screen Page 8 sees 156 Figure 91 CWF Part A Inquiry Reply Screen Page 9 ssssessssesseseeeeeeeeeenne nennen 157 Figure 92 CWF Part A Inquiry Reply Screen Page 10 seen 157 Figure 93 CWF Part A Inquiry Reply Screen Page 11
142. e beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA TECH Technical PROF Professional PULMONARY The total number of technical and professional Pulmonary Rehabilitation services REMAINING remaining CARDIAC The total number of professional and technical Cardiac Rehabilitation services used APPLIED ICR APPLIED The total number of professional and technical Intensive Cardiac Rehabilitation Services used Palmetto GBA Page 159 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 12 Field definitions and completion requirements are provided in the table following Figure 94 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 94 CWF PartA Inquiry Reply Screen Page 12 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA REC HCPCS Record HCPCS Identifies the HCPCS f
143. ecord was transmitted to the CWF CWF DISP CD The CWF Disposition Code Valid values include 01 Debit accepted no automated adjustment 02 Debit accepted automated adjustment 03 Cancel accepted 04 Outpatient history only accepted 50 Not in file NIF 51 True NIF on HCFA Batch System Palmetto GBA September 2015 Page 101 Section 5 Claim Entry DDE User s Manual Field Name Description 52 Mater record housed at another CWF site 53 Record in HCFA alpha match 55 Name personal character mismatch 57 Beneficiary record archived only skeleton exists 58 Beneficiary record blocked for cross reference 59 Beneficiary record frozen for clerical correction 60 Input output error on data 61 Cross reference database problem AB Transaction caused CICS abnormal end of job abend BT History claim not present to support spell Cl CICS processing error CR Crossover reject ER Consistency edit reject UR Utilization reject RD Transaction Error REMARK Valid Remark Narrative types include NARRATIVE M1 Method M2 Method Il 382 EFFECTIVE The method effective date Valid values are DATE Y The 382 effective date is equal to the 382 signature date N The 382 effective date will be January 1 of the following year TERM DATE Projected date of termination of dialysis coverage Palmetto GBA Page 102 September 2015 Section 6 Claim Correction DDE User s Manual
144. eed for total charges used for multiple HCPC for single revenue code centers RHC or CORF psychiatric EGHP may only be used on the 0001 total line for MSP Non EGHP may only be used on the 0001 total line for MSP IRS SSA data match project MSP cost avoided Note This field is displayed on the screen as O V R FEE Displays the fee indicator received in the Physician Fee Schedule file Valid values include B Bundled Procedure R Rehab Audiology Function Test CORF Services ROD Xzzo Space Note This field is displayed on the screen as F E E Palmetto GBA Page 47 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description OPH The Outpatient Hospital Indicator with six occurrences displays the outpatient hospital indicator received in the Physician Fee Schedule abstract test file Valid values are 0 Fee applicable in Hospital Outpatient Setting 1 Fee not applicable in Hospital Outpatient Setting lt Space Note This field is displayed on the screen as O P H CAT Category Code This field identifies the CMS category of the DME equipment T Inexpensive or routinely purchased DME 2 DME items requiring frequent maintenance and substantial servicing 3 Certain customized DME items 4 Prosthetic or orthotic devices 5 Capped rental DME items 6 Oxygen and oxygen equipment Note This field is disp
145. eld Name Description PROVIDER Automatically filled with the provider number but accessible if the provider is authorized to view other provider numbers Palmetto GBA Page 57 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description S LOC The status location of the claim can be used as search criteria CAT The category can be used as search criteria NPI Identifies the provider s National Provider Identifier NPI S LOC The status location identifies the condition of the claim and or location of the claim CAT The Bill Category identifies the type of claims in specific locations by Type of Bill In addition a value that identifies the total claim number for each status location Valid values include NN First two digits of any TOB appropriate to the provider e g 11 13 32 72 etc MP Medical Policy Medical policy applies to claims in a status of T and a location of B9997 only It identifies RTP d claims where the first digit of the primary reason code is a 5 Claims in this category are also counted under the standard bill category Claims in this category are not included in the total count TC category NM Non Medical Policy Applies to claims in a status of T and a location of B9997 only It identifies RTP d claims where the first digit of the primary reason code is not a 5 Claims in this category are also counted under the standard bill category Claims in
146. eneficiary already received the service DODNOELG Beneficiary not eligible due to date of death Palmetto GBA Page 155 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Pages 8 Field definitions and completion requirements are provided in the table following Figure 90 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 90 CWF Part A Inquiry Reply Screen Page 8 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA COUNSELING Identifies up to five years of counseling data Valid values include PERIOD T one year 2 two years 3 three years 4 four years 5 five years TOTAL Identifies the number of sessions billed for the beneficiary SESSIONS HCPCS HCPCS Code FROM From date of claim THRU Through date of claim PER Identifies up to five years of counseling data Valid values include T one year 2 two years 3 three years 4 four years 5 five years QT Quantity The number of services billed for each date TP Claim type Palmet
147. er s Manual Field Name Description CCYY MM DD format Transplant Info COV IND The Transplant Covered Indicator Valid values are Y Covered Transplant N Non covered Transplant TRAN IND The type of transplant performed Valid values are 1 Allogeneous Bone Marrow 2 Autologous Bone Marrow H Heart Transplant K Kidney Transplant L Liver Transplant DIS DATE The discharge date for the transplant patient There may be up to three discharge dates displayed HHPPS Home Health Prospective Payment System EPISODE START The start date of an episode EPISODE END The end date of an episode DOEBA The first service date of the HHPPS period DOLBA The last service date of the HHPPS period Screen 9 MAP1758 Field descriptions are provided in the table following Figure 14 MAP1758 JM MAC VA WV UAT 11003 Sc ACCEPTED HOSPICE INFO FOR PERIODS 1 AND 2 PERIOD 1ST ST DATE INTER OWNER CHANGE ST DATE INTER 2ND ST DATE PROV TERM DATE OWNER CHANGE ST DATE INTER 1ST BILLED DT LAST BILLED DT DAYS BILLED REVO IND PERIOD 1ST ST DATE OWNER CHANGE ST DATE 2ND ST DATE PROV OWNER CHANGE ST DATE 1ST BILLED DT LAST BILLED DT DAYS BILLED REVO IND PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 14 Beneficiary CWF Screen 9 Palmetto GBA Page 24 September 2015 Section 4 Claim Inquiry MAP175C DDE User s Manual JM MAC VA WV UAT 11003
148. er to the on line reason code file NPC Non payment code used by the system to deny or reject charges Valid values are B Benefits exhausted C Non covered care discontinued E First claim development Contractor 11107 F Trauma code development Contractor 11108 G Secondary claims investigation Contractor 11109 H Self reports Contractor 11110 J 411 25 Contractor 11111 K Insurer voluntary reporting Contractor 11106 N All other reasons for non payment P Payment requested Q MSP Voluntary Agreements Contractor 88888 Q Employer Voluntary Reporting Contractor 11105 R Spell of illness benefits refused certification refused failure to submit evidence provider responsible for not filing timely or waiver of liability T MSP Initial Enrollment Questionnaire Contractor 99999 T 2 MSP Initial Enrollment Questionnaire Contractor 11101 U MSP HMO Cell Rate Adjustment Contractor 55555 U HMO Rate Cell Contractor 11103 V MSP Litigation Settlement Contractor 33333 W Workers Compensation X MSP cost avoided Y IRS SSA data match project MSP cost avoided Contractor 77777 Y IRS SSA CMS Data Match Project Cost Avoided Contractor 11102 Z System set for type of bills 322 and 332 containing dates of service 10 01 00 or greater and submitted as an MSP primary claim this code allows the FISS to process the claim to CWF and allows CWF to accept the claim as billed 00 COB Contrac
149. er toll free at 855 696 0705 for assistance After you correctly enter your User ID and password the TPX Menu Screen Figure 2 will display TPX MENU FOR Session Description Command gt Figure 2 TPX Menu Screen North Carolina providers should select the JM MAC FISS Prod N Carolina session from the menu by entering S on the green line Then press ENTER South Carolina Part A and HHH providers should select the JM MAC FISS PROD SC HHH session from the menu by entering S on the green line Then press ENTER Virginia and West Virginia Part A providers should select the JM MAC FISS PROD VA WV session from the menu by entering S on the green line Then press ENTER Final Connectivity Instructions Instructions listed below are for all providers 1 Type FSSO F S S zero directly over the screen message and press ENTER Note You must type a numeric zero when typing in FSSO If you accidentally type an alpha O the system will give you an error message 2 The Main Menu Figure 3 will display From the Main Menu you may select the function you wish to perform on the DDE system Refer to the appropriate section of this manual for the function you wish to use Palmetto GBA Page 6 September 2015 Section 2 Connection Instructions DDE User s Manual MAP1701 JM MAC SC HHH UAT 11001 MAIN MENU INQUIRIES CLAIMS ATTACHMENTS CLAIMS CORRECTION ONLINE REPORTS ENTER MENU SELECTION PLEAS
150. ermined LOS based on certain claim data three digit field in 99 9 format OUTLIER DAY Outlier day cutover Identifies the outlier day cutover amount three digit field in CUTOVER 99 9 format OPERATING DSH Operating payment disproportionate share Identifies the operating payment disproportionate share amount eight digit field in 999 999 99 format PAYMENT IME Operating payment indirect medical education Identifies the operating payment indirect medical education amount eight digit field in 999 999 99 format CAPITAL DSH Capital payment disproportionate share Identifies the capital payment disproportionate share amount eight digit field in 999 999 99 format PAYMENT IME Capital payment indirect medical education Identifies the capital payment indirect medical education amount eight digit field in 999 999 99 format OPERATING Operating payment Identifies the total amount for operating payments eight PAYMENT digit field in 999 999 99 format CAPITAL Capital payment Identifies the total amount for capital payments eight digit PAYMENT field in 999 999 99 format TOTAL PAYMENT Total Payment Identifies the total amount of payments eight digit field in 999 999 99 format Palmetto GBA Page 36 September 2015 Section 4 Claim Inquiry DDE User s Manual DRG Cost Disclosure Inquiry MAP1783 Field descriptions are provided in the table following Figure 21 JM MAC VA WV UAT 1100
151. es X The end of POA indicators for principal and if applicable other diagnoses in special processing situations that may be identified by CMS in the future Not acute care POA s do not apply NPI The provider s National Provider Identifier NPI number SEX The Beneficiary s Sex C l Century Indicator If you enter D O B date of birth you must enter the century indicator Valid values are 8 1800 1899 9 1900 1999 2 2000 DISCHARGE The Patient s Discharge Status Code Refer to UB 04 Manual for valid values STATUS DT The date the patient was discharged in MMDDYY format PROV The provider s Medicare provider number REVIEW CODE Indicates the code used in calculating the standard payment Valid values are 00 Pay with outlier Calculates standard payment and attempts to pay only cost outliers 01 Pay days outlier Calculates standard payment and the day outlier portion of the payment if the covered days exceed the outlier cutoff for DRG 02 Pay cost outlier Calculates the standard payment and the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold if the length of stay exceeds the outlier cutoff no payment is made and a return code of 60 is returned 03 Pay per diem days Calculates a per diem payment based on the standard payment if the covered days are less than the average length of stay for the DRG if the covered days equal or exceed the
152. escriptions are provided in the table following Figure 60 MAP1661 JM A B MAC SC HHH 11001 ACPFA391 09 01 15 REPORT VIEW INQUIRY C201533P 14 58 56 REPORT FREQUENCY SCROLL KEY PAGE SEARCH REPORT 050 SUBM 001 PAGE 1 CYCLE DATE 08 31 15 VIDER FREQUENCY DAILY PROVIDER FAS RUN TIME 6 23 FOR PROVIDE ADMIT COV FM COV TO TOTAL CHGS HIC CERT SSNO PCN 063015 063015 063015 1 178 63 TO A MANIFESTATION TOTAL RETURNED CLAIM 1 178 63 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF10 LEFT Figure 60 050 Claims Returned to Provider Scroll Right View Palmetto GBA Page 115 September 2015 Section 7 Online Reports DDE User s Manual Field Name Description REPORT Identifies the unique number assigned to the Claims Returned to Provider report SCROLL Indicates which side of the report you are viewing Scroll L is the left side of the report and Scroll R is the right side Press the F11 and F10 keys to move right and left KEY The provider number SEARCH Allows searching for specific information contained in report fields by using F2 REPORT Identifies the unique number assigned to the Claims Returned to Provider report PAGE The specific page you are viewing within the report CYCLE DATE Identifies the production cycle date in MMDDYY format FREQUENCY The frequency the report is run PROVIDER Identifies t
153. f birth MMDDCCYY SX Sex Beneficiary s sex code Palmetto GBA Page 154 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual Field Name Description INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA Preventive Services CARDIOVASC Cardiovascular COLORECTAL Colorectal FOB TEST Fecal Occult Blood Test IPP EXAM Initial Preventive Physical Examination PCB EXAM Pelvic and Clinical Breast Examination PPV Pneumococcal Pneumonia Vaccine PROSTATE Prostate PAP TEST Pap Smear Test DIABETES Diabetes GLAU Glaucoma MAMM Mammography PAPT Pap Smear Test AAA Abdominal Aortic Aneurysm AWV Annual Wellness Visit IPP EXAM Initial Preventive Physical Examination BLANK Healthcare Common Procedure Coding System HCPCS code for the preventive service TECH DTE Next eligible technical date for the preventive service listed PROF DTE Next eligible professional date for the preventive service listed The TECH DTE and PROF DTE may show abbreviations in the MMDDYYYY field Some common abbreviations that may occur include AGENOELG Beneficiary not eligible due to age GDRNOELG Beneficiary not eligible due to gender NOPTBENT Beneficiary not entitled to Part B 00000000 Service not applicable SRVNOELG Beneficiary not eligible for the service VACCINTD Beneficiary already vaccinated RECEIVED B
154. formation INST Claim Entry Screen Page 5 MAP1715 Field descriptions are provided in the MAP1715 HIC INSURED NAME REL CERT SSN HIC SEX GROUP NAME TREAT AUTH TREAT AUTH TREAT AUTH PROCESS COMPLETED PAGE 05 SC table following Figure 47 JM MAC SC HHH UAT 11001 INST CLAIM ENTRY TOB S LOC PROVIDER DOB INS GROUP NUMBER CODE CODE CODE PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PF8 NEXT PF9 UPDT Figure 47 UB 04 Claim Entry Page 5 HIC 60 The beneficiary s Medicare Health Insurance Claim number TOB 4 The Type of Bill identifies type of facility type of care source and frequency of this claim in a particular period of care Refer to your UB 04 Manual for valid values S LOC The Status code identifies the condition and of the claim within the system The Location code identifies where the claim resides within the system PROVIDER 57 This field displays the provider identification number INSURED 58 A Maximum of 25 digits Last Name First Name On the same line that Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description NAME B C corresponds to the line on which Medicare payer information is reported A C enter patient s name as reported on his her Medicare health insurance card If billing supplemental insurance enter the name of the individual insured under Medicare on line
155. g Veterans VA L Liability W Workers Compensation set aside DESCRIPTION Type of primary insurance plan Working Aged Disabled Workers Comp etc EFF DATE Effective Date The effective date of the primary plan TRM DATE Termination Date The termination date of the primary plan if applicable INTER The Medicare contractor number associated with the source of the MSP information DOA Date of Accretion the date the MSP record was established in CWF PalmettoGBA EE Page 152 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 5 Field definitions and completion requirements are provided in the table following Figure 87 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 87 CWF Part A Inquiry Reply Screen Page 5 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code PLAN TYPE Medicare Advantage MA Plan HMO Type such as PPO PLAN ID Medicare Advantage MA Plan HMO Identification Code Valid values are Position 1 H 2 amp 3 State Code 4 amp 5 HMO Number within the state OPT MA Plan HMO Option Code Describes the type of plan the beneficiary selec
156. gives Medicare providers direct access to the CMS s CWF Host database Providers may query a Beneficiary s Master Record The beneficiary s record contains Medicare entitlement hospice benefit information Medicare Advantage MA Plan also known as Medicare health maintenance organization HMO information and other payer information Each beneficiary record is located at one of nine CWF Host sites CWF edits claims for validity entitlement remaining benefits and deductible status A reply from CWF will be returned the following day The majority of claims will be accepted by CWF for remittance Others will reject open for recycle at a later date or suspend for investigative action The objectives of the CWF are to provide Complete beneficiary information to Medicare contractors such as Palmetto GBA Entitlement data Utilization data Claim history Information in a timely manner via an online process Accurate initial claims processing with Deductible access Coinsurance access Part A and Part B benefits paid comparison Check editing prepayment so contractor s approval equals CMS acceptance Duplicate payments prevention Efficient implementation of future benefits and enhancements changes Part A CWF Send Process The Medicare contractor or satellite uses its best available information on beneficiary eligibility and remaining benefits to fully adjudicate claims Every claim has been grouped priced and evaluate
157. gure 97 CWF INQUIRY REPLY HIBC COUNSELLING PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 97 CWF PartA Inquiry Reply Screen Page 15 Field Name Description High Intensity Behavioral Counseling HIBC Counselling CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA STIS Sexually Transmitted Infections This field identifies the codes billed for STI screening NEXT ELIG Next Eligible Technical Date This field identifies the next date the patient is TECH DATE eligible for the technical component of the screening NEXT ELIG Next Eligible Professional Date This field identifies the next date the patient is PROF DATE _ eligible for the professional component of the screening Palmetto GBA Page 163 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 14 Field definitions and completion requirements are provided in the table following Figure 98 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 98 CWF PartA Inquiry Reply Screen Page 16 Field Name Description Claim Number Shows the benefi
158. h Insurance Query DDE User s Manual HIQA Page 14 Field descriptions for Page 14 of the HIQA screen are provided in the table following Figure 79 CWF INQUIRY REPLY HIBC COUNSELLING PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 79 CWF PartA Inquiry Reply Screen Page 14 Field Name Description High Intensity Behavioral Counseling HIBC Counseling CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA STIS Sexually Transmitted Infections This field identifies the codes billed for STI screening NEXT ELIG Next Eligible Technical Date This field identifies the next date the patient is TECH DATE eligible for the technical component of the screening NEXT ELIG Next Eligible Professional Date This field identifies the next date the patient is PROF DATE _ eligible for the professional component of the screening Palmetto GBA Page 141 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 15 Field descriptions for Page 15 of the HIQA screen are provided in the table following Figure 80 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7
159. h beneficiary record is located at one of nine CWF Host sites CWF edits claims for validity entitlement remaining benefits and deductible status A reply from CWF will be returned the following day The majority of claims will be accepted by CWF for remittance Others will reject open for recycle at a later date or suspend for investigative action The objectives of the CWF are to provide Complete beneficiary information to Medicare contractors as Entitlement data Utilization data Claim history Information in a timely manner via an online process Accurate initial claims processing with Deductible access Coinsurance access Part A and Part B benefits paid comparison Check editing prepayment so contractor s approval equals CMS acceptance Duplicate payments prevention Efficient implementation of future benefits and enhancements changes Part A CWF Send Process The Medicare contractor or satellite uses its best available information on beneficiary eligibility and remaining benefits to fully adjudicate claims Every claim has been grouped priced and evaluated for Medicare Secondary Payer involvement and has its final reimbursement including interest before it is sent High Speed bulk data transfer transmits the Medicare contractor paid claim to the host for approval Prior to SEND the Medicare contractor converts adjudicated claims from in house format to CWF format This is known as the best shot approach
160. he facility that rendered services for the claims being returned RUN TIME The time of the production cycle that produced the reports FOR PROVIDER The provider name and address for report remittance This information is taken from the Provider File and is a total of 4 lines of 31 characters each HIC CERT SSNO beneficiary listed in the name field Identifies the Health Insurance Claim Number submitted by the provider for the PCN DCN The Document Control Number identifies the returned claim TYPE OF BILL Identifies the type of facility type of care source and frequency of this claim ina particular period of care PROVIDER Identifies the facility listed on the claim NAME Lists the beneficiary s last and first name as submitted by the provider of the patient who received the services ADMIT DATE The date in MMDDYY format that the beneficiary was admitted for inpatient services or the beginning of the outpatient home health or hospice services COV FM Identifies the beginning date in MMDDYY format of services rendered to the beneficiary as indicated on the claim COV TO Identifies the ending date of services rendered to the beneficiary as indicated on the claim TOTAL CHGS Displays the total charges as submitted by the provider REASON CODE AND Displays the reason code s and narrative for the returned claim There is a maximum of 150 occurrences for each reason code narrative N
161. hnical Date This field identifies the date the beneficiary is eligible for preventative service coverage Note When there is not a date one of the following messages displays to explain why the beneficiary is not eligible Valid values are PTB Beneficiary is not entitled to Part B RCVD Beneficiary already received service DOD Beneficiary not eligible due to date of death GDR Beneficiary not eligible due to gender AGE Beneficiary not eligible due to age SRV Beneficiary not eligible for the service VAC Beneficiary already vaccinated Service not applicable PROF D Professional Date This date identifies the date the beneficiary is eligible for preventative service coverage Note When there is not a date one of the following messages displays to explain why the beneficiary is not eligible Valid values are PTB Beneficiary is not entitled to Part B RCVD Beneficiary already received service DOD Beneficiary not eligible due to date of death GDR Beneficiary not eligible due to gender AGE Beneficiary not eligible due to age SRV Beneficiary not eligible for the service VAC Beneficiary already vaccinated Service not applicable Screen 6 MAP1755 Field descriptions are provided in the table following Figure 11 MAP1755 JM MAC VA WV UAT 11003 ACCEPTED CLAIM NAME D O B SEX PROV PROV IND APP DT REASON CD DATE TIME REQ ID DISP CD TYPE CENT D O B D 0 D A CURR ENT DT TERM DT PRI ENT
162. iary s Medicare Part A benefits become effective TERM DT The date a beneficiary s Medicare Part A benefits were terminated PART B EFF DT The date a beneficiary s Medicare Part B benefits became effective TERM DT The date a beneficiary s Medicare Part B benefits were terminated Current Benefit Period Data FRST BILL DT The beginning date of inpatient benefit period LST BILL DT The ending date of inpatient benefit period HSP FULL DAYS The remaining full hospital days HSP PART DAYS The remaining hospital co insurance days SNF FULL DAYS The full days remaining for a skilled nursing facility SNF PART DAYS The partial days remaining for a skilled nursing facility INP DED REMAIN The Part A inpatient deductible amount the beneficiary must pay BLD DED PNTS The remaining blood deductible pints Psychiatric PSY DAYS REMAIN The remaining psychiatric days PRE PHY DYS Number of pre entitlement psychiatric days the beneficiary has used USED PSY DIS DT Date patient was discharged from a level of care INTRM DT IND Code that indicates an interim date for psychiatric services Valid values are Y Date is through date of interim bill utilization day N Discharge date not a utilization day Screen 2 MAP1752 Field descriptions are provided in the table following Figure 7 JM MAC SC HHH UAT 11001 ELIGIBILITY DETAIL INQUIRY MAP1752 RI
163. ic type of bonus This is a one position alphanumeric field Valid values are 1 HPSA 2 PSA 3 HPSA and PSA 4 HSIP 5 HPSA and HSIP 6 PCIP 7 HPSA and PCIP Not applicable NOTE The system determines the bonus eligibility status of the line based on the Offsite Zip Code field on MAP1713 in Figure 44 REV 42 The Revenue Code displays a code for a specific accommodation or service that was billed on the claim This will be the revenue code selected on MAP1712 HCPC 44 The Healthcare Common Procedure Code identifies certain medical procedures or equipment for special pricing assigned by CMS MODIFIERS 44 This field will contain five 2 character HCPCS modifiers The two modifiers entered on MAP1712 will be displayed and the user can enter any remaining modifiers SERV DATE 45 The date of service in MMDDYY format required for many outpatient bills It will be the same as the line item selected on MAP1712 SERV RATE 44 Identifies the per unit cost for a particular line item This is the rate that was entered on MAP1712 TOT UNT 46 Total Units is a quantitative measure of services rendered by revenue category The total units displayed on this screen are the same as that entered on MAP1712 COV UNT 46 Covered Units is a quantitative measure of services rendered by revenue category The covered units displayed on this screen are the same as that entered on MAP1712
164. icator is not C or Z then the amount will equal MSP Blood MSP Cash Deductible MSP Coinsurance Not displayed on new claims MSP claims cannot be submitted or corrected in DDE PAID This is the patient paid amount calculated by the system This amount is the lower of Patient Reimbursement Patient Responsibility or the remaining Patient Paid after the preceding lines have reduced the amount entered on Claim Page 3 REDUCT AMT This field identifies the 10 reduction amount by a processed 121 re billed demonstration claim that paid 90 of allowable services identified by including Claim Adjustment Reason Codes CARC 45 to report the adjustment due to difference in billed charged and allowed amount and CARC 132 to report adjustments due to a 10 reduction in conjunction with Group Code of CO This is a ten position alphanumeric field in 99999999 99 format r rommoo WrROND ANSI This field identifies the group code and the CARC code for the reduction amount above The group code is a one digit alphanumeric field Palmetto GBA Page 78 September 2015 Section 5 Claim Entry UB 04 DDE User s Manual Field Name X Ref Description PAT The patient s reimbursement responsibility paid and reduction amounts PROV The provider s reimbursement responsibility paid and reduction amounts MED The Medicare reimbursement amount
165. id values are The provider number is a Legacy or OSCAR number N The provider number is an NPI number APP DT The date the beneficiary was admitted to the hospital Application date REASON CD Reason Code Indicates the reason for the injury Valid values are 1 Status inquiry 2 Inquiry relating to an admission DATE TIME The date and time in Julian YYDDDHHMMSS format REQ ID Requested ID Identifies person submitting inquiry DISP CD The CWF disposition code assigned to a claim when it is processed through a CWF host site Valid values include 01 Part A inquiry approved beneficiary has never used Part A services Type 3 reply 02 Part A inquiry approved beneficiary has had some prior utilization 03 Part A inquiry rejected 04 Qualified approval may require further investigation 05 Qualified approval according to CMS s records this inquiry begins a new benefit period TYPE Identifies the type of CWF reply Valid value 3 Accept CENT D O B Century of the Beneficiary patient s date of birth Valid values are 8 18th Century 9 19th Century D O D Identifies the date of death of the beneficiary patient Part A CURR ENT DT Current Part A benefits entitlement date in MMDDYY format TERM DT Termination date for Part A benefits in MMDDYY format PRI ENT DT Prior entitlement date for Part A benefits in MMDDYY format TERM DT Prior termination date for Part A benefits in MMDDYY format Part B CURR ENT Current Pa
166. ider number the status location where RTP claims are stored T B9997 and the first two digits of the type of bill To narrow the selection enter any or all of the information in the following table Field Name Description DDE SORT Allows multiple sorting of displayed information Valid values include TOB DCN Current default sorting process S LOC Name M Medical Record number sort Ascending order HIC N Name sort Alpha by last name first initial Receipt Date MR HIC H HICN sort Ascending order Receipt Date MR R Reason Code sort Ascending Order Receipt Date MR HIC D Receipt Date sort Oldest Date displaying first MR HIC MEDICAL Used to narrow the claim selection for inquiry This will provide the ability to view REVIEW pending or returned claims by medical review category Valid values include SELECT Selects all claims 1 Selects all claims 2 Selects all claims excluding Medical Review 3 Selects Medical Review only To see a list of the claims that require correction press ENTER The selection screen will then display all claims that have been returned for correction status location T To narrow the scope of the claims viewed enter one of the following selection criteria type of bill from date to date and HIC number If the claim you are looking for does not display on the screen do the following Verify the HIC number that you typed Verify the f
167. ield identifies up to five years of counseling data Valid values are PERIOD 1 One year Z Two years Y Three years 4 Four years 5 Five years TOTAL This field identifies the number of sessions billed for the beneficiary Note If a SESSIONS date range is billed on a detail and a quantity that matches the range is not identified CWF posts the session as1 unit i e 10 25 10 27 Unit 1 will post as 1 session HCPCS This field identifies the Healthcare Common Procedure Coding System HCPCS code of G0375 or G0376 FROM This field displays the from date of the claim in MM DD CCYY format THRU This field displays the through date of the claim in MM DD CCYY format PER This field identifies up to five year of counseling data Valid values are T One year Z Two years Y Three years 4 Four years 5 Five years QT Quantity This field identifies the number of services billed for each date TP Claim Type This filed identifies the type of claim Valid values are O Outpatient B Part B Screen 12 MAP175L Field descriptions are provided in the table following Figure 17 MAP175L JM MAC VA WV UAT 11003 REQ DATE REC HCPCS FROM DATE REC HCPCS FROM DATE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 17 Beneficiary C WF Screen 12 Palmetto GBA Page 27 September 2015 Section 4 Claim Inquiry
168. ient s admission date in MM DD YY format DOCUMENT This field displays the claim identification number CONTROL NUMBER OSC The Occurrence Span Code that identifies events that relate to the payment of the claim FROM DATE This field identifies the beginning of an event that relates to the payment of the claim TO DATE This field identifies the ending date of the event that relates to the payment of the claim Claims Count Summary Select option 56 from the Inquiry Menu to access the Claim Summary Totals Inquiry screen This screen provides a mechanism for providers to obtain information on Total number of pending claims Total charges billed Total reimbursement for claims in each FISS status location The data on this screen updates with each nightly FISS cycle Palmetto GBA recommends that providers review this screen at the start of each day to monitor the progress of submitted claims Press ENTER to display the data applicable to the provider number identified or you can type in a specific status location or category type to narrow the search Claim Summary Totals Inquiry Screen MAP1371 Field descriptions are provided in the table following Figure 32 MAP1731 JM MAC SC HHH UAT 11001 SC ICD 9 CM CODE INQUIRY STARTING ICD9 CODE ICD9 CODE DESCRIPTION EFFECTIVE TERM DATE EFFECTIVE TERM DATE EFFECTIVE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 32 Claim Summary Totals Inquiry Screen Fi
169. iled FROM DT From Date The home health certification from date Palmetto GBA Page 160 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 13 Field definitions and completion requirements are provided in the table PF1 INQ SCREEN following Figure 95 INQUIRY REPLY PF3 CLEAR END PF7 PREV PF8 NEXT Figure 95 CWF PartA Inquiry Reply Screen Page 13 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA TELEHEALTH Telehealth services rendered under hospital care SERVICES HOSPITAL CARE TELEHEALTH Telehealth services rendered under nursing care SERVICES NURSING CARE HCPCS The HCPCS codes billed NEXT The beneficiary s next eligible date for services ELIGIBILE DATE RULE The Allowed HCPCS with modifier and how often Palmetto GBA September 2015 Page 161 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 14 Field definitions and completion requirements are provided in the table following Figure 96 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT
170. im this includes the 001 revenue code line The system will input the revenue code line number when F9 is pressed It will be present for update and inquiry REV 42 The Revenue Code for a specific accommodation or service that was billed on the claim Valid values are 0001 through 9999 e List revenue codes in an ascending sequence and do not repeat revenue codes on the same bill if possible Palmetto GBA Page 71 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name x Ref Description e To limit line item entries on each bill report each revenue code only once except when distinct HCPCS code reporting requires repeating a revenue code e g laboratory services revenue code 300 repeated with different HCPCS codes an accommodation revenue code that requires repeating with a different rate or when mandated per CMS regulations e Revenue code 001 total charges and units should always be the final revenue code entry e Some codes require CPT HCPCS codes units and or rates HCPC 44 Enter the HCPCS code describing the service if applicable HCPCS coding must be reported for specific outpatient services including but not limited to e Outpatient clinical diagnostic laboratory services billed to Medicare enter the HCPCS code describing the lab service Outpatient hospital bills for Medicare defined surgery procedure Outpatient hospital bills for outpatient par
171. im Entry Field Name HCPC MOD IN UB 04 X Ref 44 DDE User s Manual Description Identifies if the HCPC Code Modifier or REV Code was changed Valid values are U Up coding D Down coding Blank A U or D in this field opens the REV Code and HCPC Mod fields to accept the changed code Enter U or D tab down to the REV Code and HCPC MOD fields After the new code is entered the original Rev Code and HCPC MOD fields move down to the ORIG REV or ORIG HCPC MOD field HCPC 44 Identifies the HCPC code that further defines the revenue code being submitted The information on this field was entered on MAP1712 MODIFIERS 44 Identifies the HCPCS modifier codes for claim processing This field may contain five 2 position modifiers SERV DATE 45 The line item date of service in MMDDYY format and is required for many outpatient bills This information was entered on MAP1712 COV UNT COV CHRG 46 47 being denied The number of covered units associated with the revenue code line item The number of covered charges associated with the revenue code line item being denied ADR Identifies the Additional Development Reason Codes that are present on the screen and allows the user to manually enter up to four occurrences to be used when an ADR letter is to be sent The system reads the ADR code narrative to print the letter The letter prints the reason code narrat
172. ing with 99 Sequence 13 Choices Split Site specific field used on split bills Valid values include C Medicare Choices Claim E ESRD Managed Care V VA Demo P Encounter Claim 0 When not used at a site Palmetto GBA Page 3 September 2015 Section 1 Introduction DDE User s Manual ae Definition Position 14 Origin Code designating method of claim entry into the system Valid values are 0 Unknown 1 EMC UB 04 CMS Format 2 EMC Tape UB 04 Other Format 3 EMC Tape Other Other is defined as PRO Automated Adjustment for FISS 4 EMC Telecom UB 04 DDE Claim 5 EMC Telecom Not UB 04 6 Other EMC UB 04 7 Other EMC Not UB 04 8 UB 04 Hardcopy 9 Other Hardcopy 15 17 Business This is a three position alphanumeric field The first two characters are the Segment jurisdiction code For Fiscal Intermediary Carrier and Regional Home Identifier BSI Health Intermediary Workloads the code is the Official United States Postal Service USPS state abbreviation for the state jurisdiction For Durable Medical Equipment Regional Carriers these two positions identify the DME region for example Region A is RA The next character identifies the type of Medicare FFS contract Fiscal Intermediary A Carrier B Regional Home Health Intermediary R or Durable Medical Equipment Regional Carrier D 18 21 Home Health Home Health Split ad D The DCN number has been altered due to a file
173. inquire or input information TAB to the OSCAR field and type in the provider number Palmetto GBA Page 65 September 2015 Section 5 Claim Entry DDE User s Manual MAP1703 JM MAC SC HHH UAT 11001 CLAIM AND ATTACHMENTS ENTRY MENU CLAIMS ENTRY INPATIENT OUTPATIENT SNF HOME HEALTH HOSPICE NOE NOA ROSTER BILL ENTRY ATTACHMENT ENTRY HOME HEALTH DME HISTORY ESRD CMS 382 FORM ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 39 Claim and Attachments Entry Menu Electronic UB 04 Claim Entry When entering UB 04s select the option from the Claim and Attachments Entry Menu that best describes your Medicare line of business Inpatient 20 Outpatient 22 SNF 24 Home Health 26 Hospice 28 Hospice Elections 4 UB 04 Claim Entry Page 1 After you select an option page one of the UB 04 Claim Entry screen Figure 40 will display The screen will include the OSCAR Provider Number Type of Bill and default Status Location S B0100 You must enter the beneficiary information name address date of birth etc and any other information needed to process the claim Palmetto GBA Page 66 September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Page 1 MAP1711 Field descriptions are provided in the table following Figure 40 MAP1711 PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY TOB S LOC OSCAR SV UB FORM TRANS HOSP PROV PROCESS NEW HIC TAX
174. ions such as interest HOSPITAL The hospital portion of the total blended payment SPECIFIC PORTION FEDERAL The Federal portion of the total blended payment SPECIFIC PORTION DISP SHARE The percentage of a hospital total Medicare Part A patient days attributable to HOSPITAL AMT Medicare patients who are also SSI PASS THRU PER Identifies the pass through discharge cost DISCHARGE OUTLIER PORTION The dollar amount calculated that reflects the outlier portion of the charges PTPD TEP The sum of the pass through per discharge cost plus the total blended payment amount STANDARD The number of regular Medicare Part A days covered for this claim DAYS USED LTR DAYS USED The number of lifetime Reserve Days used during this benefit period Palmetto GBA September 2015 Section 4 Claim Inquiry Field Name DDE User s Manual Description PROV REIM The actual payment amount to the provider for this claim This will be the amount on the Remittance Advice Voucher DRG PPS Screen MAP178B Field Descriptors are in the table that follows Figure 19 JM MAC VA WV UAT 11003 Sc DRG PPS INQUIRY DIAGNOSES 2 7 PROCEDURES 2 6 6 7 DISCHARGE STATUS REVIEW CODE TOTAL CHARGES APPROVED LOS COV DAYS RETURNED FROM GROUPER D R G PROC CD USED RETURNED FROM PRICER UNCOMP CARE AMT BUNDLE ADJ AMT VAL PURC ADJ AMT READMIS ADJ AMT PPS STNDRD VALUE PPS HAC PAY AMT PPS FLX7 AMT EHR PAY AD
175. ious attachments The UB 04 Claim Entry consists of six 6 separate screens pages Page01 Patient information corresponds to form locators 1 41 Page02 Revenue HCPCS codes and charges corresponds to form locators 42 49 Page03 Payer information diagnoses procedure codes corresponds to form locators 50 57 and 67 83 Page04 Remarks and attachments corresponds to form locators 80 Page05 Other payer and MSP information corresponds to form locators 58 66 Page06 MSP information crossover and detail claim inquiry does not correspond to any form locator NOTE MSP claims cannot be submitted or corrected in DDE General Information The online system defaults to the 111 type of bill for inpatient claims option 20 131 for outpatient claims option 22 and 211 for SNF claims option 24 322 for Home Health claims option 26 and 811 for Hospice claims option 28 If you are entering a different type of bill then type over the default with the correct type of bill Onthe bottom of each screen is a list of the PF function keys and the functions they perform Held names within DDE will not always follow the same order as found on the UB 04 claim form In order to help alleviate confusion the UB 04 X REF field on each page directs you to the field that correlates to the UB 04 form For valid values associated with the claim entry field please refer to your current Uniform Billing manual The UB 04 X RE
176. iry DDE User s Manual Reason Codes Inquiry Select option 17 from the Inquiry Menu to access the Reason Codes Inquiry screen Reason codes are applied to all claims processed in FISS There can be one or more reason codes applied to a claim This screen displays the narrative for the reason code s assigned to the claim For claims that are Returned to the Provider RTP for correction rejected or denied the narrative also explains the error that was identified on the claim For RTP claims the narrative may also explain what fields need to be changed or completed in order to resubmit the claim for processing The Reason Codes File contains the following data Reason code identification number and effective termination date Alternative reason code identification number and effective termination date Status and location set on the claim Post payment location Reason code narrative Clean claim indicator Additional Development Request ADR orbit counter and frequency To start the inquiry process enter the five digit numeric reason code applied to the claim and press ENTER To make additional inquiries type over the reason code with next reason code and press ENTER Reason Codes Inquiry Screen MAP1881 Field descriptions are provided in the table following the examples shown in Figures 29 MAP1881 JM MAC SC HHH UAT 11001 SC REASON CODES INQUIRY MNT PLAN REAS NARR EFF MSN EFF TERM EMC HC PRO PP cc IND CODE
177. is code used by the Grouper program for calculation Returned From Pricer PRICER The program version number for the Pricer program used VERSION RTN CD A Return Code that identifies the status of the claim when it has returned from the Pricer program WAGE INDEX Provider s wage index factor for the state where the services were provided to determine reimbursement rates for the services rendered OUTLIER DAYS The number of outlier days that exceed the cutoff point for the applicable DRG AVG LENGTH OF STAY OUTLIER DAYS THRESHOLD The predetermined average length of stay for the assigned DRG Shows the number of days of utilization permissible for this claim s DRG code Day outlier payment is made when the length of stay including days for a beneficiary awaiting SNF placement exceeds the length of stay for a specific DRG plus the CMS mandated adjustment calculation OUTLIER COST Additional payment amount for claims with extraordinarily high charges Payment THRES is based on the applicable Federal rate percentage times 75 of the difference between the hospital s cost for the discharge and the threshold established for the DRG INDIRECT The amount of adjustment calculated by the Pricer for teaching hospitals TEACHING ADJ TOTAL BLENDED The total PPS payment amount consisting of the Federal hospital outlier and PAYMENT indirect teaching reductions such as Gramm Rudman or addit
178. itial This field displays the beneficiary s correct initial of the first name The initial in this field will be different only if the initial entered in the inquiry screen Figure 83 is not consistent with CMS s record DB Corrected Date of Birth This field displays the beneficiary s correct date of birth The date of birth in this field will be different only if the date of birth entered in the inquiry screen Figure 83 is not consistent with CMS s record SX Corrected Sex Codes This field displays the beneficiary s correct sex The sex code in this field will be different only if the sex code entered in the inquiry screen Figure 83 is not consistent with CMS s record A ENT Part A Entitlement Date of entitlement to Part A benefits in a MMDDYY format A TRM Part A Termination Indicates date of termination of Part A entitlement when applicable in a MMDDYY format Otherwise this field will display all zeros B ENT Part B Entitlement Date of entitlement to Part B benefits in MMDDYY format B TRM Part B Termination Indicates date of termination of Part B entitlement when applicable in MMDDYY format Otherwise this field will display all zeros DOD Date of Death If the beneficiary is alive the field will be all zeros PART B YR Most Recent Part B Year From the applicable date input field DED TBM Deductible To Be Met Amount of the Part B cash deductible remaining to be met for the current year PT APL Physical
179. ive as they appear on each revenue code line FMR The Focused Medical Review Suspense Codes identify when a claim is edited in the system based on a parameter in the Medical Policy Parameter file The system generates the Medical Review code for the corresponding line item on the second page of the Denial Non Covered Charges screen The system assigns the same Focused Medical Review ID edits on lines that are duplicated for multiple denial reasons The user may enter or overlay any existing Medical Review suspense codes Claim level suspense codes should not apply to the line level The Medical Policy reasons are defined by a 5 or 7 in the first position of the reason code ORIG Identifies the original HCPC billed and modifiers billed accommodating a 5 digit HCPC and up to 5 2 digit modifiers MR ORIG REV Identifies the Original Revenue Code billed This field indicates if the service received complex manual medical review The valid values are The services did not receive manual medical review default value Y Medical records received This service received complex manual medical review N Medical records were not received This service received routine manual medial review ODC This field identifies original denial reason codes OCE OVR The OCE Override is used to override the way the OCE module controls the line item Valid values include 0 OCE line item denial or rejection
180. l for answers to your question before you contact Customer Support The guidelines in the manual may answer your question and eliminate the need for you to contact a Customer Support Representative For questions and information not covered in this manual please call the Provider Contact Center at 855 696 0705 Keyboard The following table provides an overview of common keyboard commands and their respective functions and language related to navigating the DDE system Command Term Function The cursor is the flashing underline that identifies where you are in what field you Cursor are located on the screen Use the keyboard arrow keys to move one character at a time in any direction within gt a field Y TAB Press the tab key to advance to the next field SHIFT Press and hold down the SHIFT key while you press the TAB key to move back to TAB the previous field When your cursor is in the top field this SHIFT TAB will move your cursor to the bottom field In examples shown in this manual an n indicates a variable number from 0 to 9 n One or more numbers may show as variables For example 72n represents the numbers 720 729 while 72nnn represents the numbers 72000 72999 If your screen freezes or locks up press and hold down the Control key while you press the letter R This will reset the screen Note Do not use this key combination ICTREFRI if you see the clock s
181. laim PAT CNTL 3a Patient Control Number The patient s unique number assigned by the provider to facilitate retrieval of individual patient records and posting of the payment TAX SUB This field identifies the number assigned to the provider by the Federal Government for tax reporting purposes TAXO CD This field identifies a collection of unique alphanumeric codes known as the provider taxonomy code The code set is structured into three distinct levels including provider type classification and area of specialization STMT DATES DAYS COV FROM and TO 6 in MMDDYY format The statement covers from and to dates of the period covered by this bill Indicates the total number of covered days This field is skipped on Home Health and Hospice claims e Enter the total number of covered days during the billing period within the From and Through dates in UB 04 X REF 6 Statement Covers Period which are applicable to the cost report including lifetime reserve days elected for which hospital requested Medicare payment e The numeric entry reported in this UB 04 X REF should be the same total as the total number of covered accommodation units reported in UB 04 X REF 46 e Exclude any days classified as non covered see UB 04 X REF 8 Non covered Days and leave of absence days e Exclude the day of discharge or death unless the patient is admitted and discharged the same day D
182. laim Entry Page 5 eese eene nnne rennen rennen enses 94 Figure 48 UB 04 Claim Entry Page 6 sees nennen nennen nnne 96 Figure 49 DDE Roster Bill Page ertt trente ri neta abe ord pori yo REF aet do hara 98 Figure 50 ESRD CMS 382 Inquiry Form sees enne n eren nest ne entren nenn nennen 100 Figure 51 Claim and Attachments Correction Menu esee eene 103 Figure 52 Claim Summary Inquiry eese ener enne rennen eren entente nenne 104 Figure 53 UB 04 Claim Entry Page 1 sees en eren erstes trennen nnne 106 Figure 54 Reason Codes Inquiry Screen ener nre 107 Figure 55 Online Report Menu teri reete tercer eer paene ene dpud Leah pa ne ETAGE abdo beds 111 Figure 56 R1 Summary of Reports Online Reports Selection eee 112 bigure 57 R2 View A Repott oie tr ER E D Tee Ra er d HUE REED E uiu ERS 113 Figure 58 R3 Credit Balance Report Form 838 Inquiry eese 114 Figure 59 050 Claims Returned to Provider Scroll Left View eene 115 Figure 60 050 Claims Returned to Provider Scroll Right View 0 ccc ceeceeceseceseeeeeeeeeeeaeeeeeeeeenaes 115 Figure 61 201 Pended Processed and Returned Claims Scroll Left View esses 117 Figure 62 201 Pended Processed and Returned Claims Scroll Right View sess 117 Figure
183. laim could RTP again in batch processing When the corrected claim has been successfully updated the claim will disappear from the screen The following message will appear at the bottom of the screen PROCESS COMPLETED ENTER NEXT DATA RTP SELECTION PROCESS From the Claim Summary Screen Figure 52 select the claim to be corrected by tabbing to the SEL field for the first line of the claim to be corrected Type a U or S and press ENTER The patient s original UB 04 claim will display This will be MAP1711 the first page of the claim Type Information Use the Function keys listed at the bottom of the screen to move through the claim i e F8 to go to the next screen F7 to back up a screen The Revenue Code screen has multiple sub screens If you have more revenue codes than can fit on one screen press F6 to go the next sub screen Press F5 to go back to the first screen You can also get from page to page by entering the page number in the top left of the screen Reason Codes will appear at the bottom of the screen Figure 53 to explain why the claim was returned Up to ten reason codes can appear on a claim INST Claim Update Screen Claim Page 1 MAP1711 MAP1711 PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM UPDATE HIC TOB S LOC OSCAR SV UB FORM NPI TRANS HOSP PROV PROCESS NEW HIC PAT CNTL TAX SUB TAXO CD STMT DATES FROM TO DAYS COV N C co LTR FIRST MI DOB 2 4 6 SEX MS AD
184. laims When non covered charges are present on the bill remarks are required in UB 04 X REF 80 SERV DT 45 The service date is required for every line item where a HCPCS code is required effective April 1 2000 including claims where the from and through dates are equal Inpatient Rehabilitation Facility IRF PPS claims this field is not required on the Revenue Code 0024 line However if present on the Revenue Code 0024 line it indicates the date the Provider transmitted the patient assessment This date if present must be equal to or greater than the discharge date Statement Cover To Date RED IND This field identifies if the payment for the line was paid using the therapy reduced rate Not required for new claims entry UB 04 CLAIM ENTRY PAGE 2 ADDITIONAL NPI LINES This screen displays additional NPI lines and National Drug Code NDC fields This screen can be accessed by pressing F11 from the revenue code line screen MAP1712 Palmetto GBA Page 72 September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Screen Page 2 Additional NPI Lines MAP171E Field Descriptions are provided in the table following figure 42 MAP171E PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY NDC CD PAGE TOB S LOC PROVIDER RETURN NDC FIELD NDC QUANTITY QUALIFIER HIPPS1 HIPPS2 L SC L Sc Sc SC Sc Nie Nie PROCESS COMPLETED PLEASE CONTINUE PRESS PF2 1712 PF3 EX
185. layed in record type standard code sequence S Code selection field to select a specific code from the listing RT The record type selected CODE The standard code selected TERM DT The date the ANSI standard code is deactivated in MMDDYY format NARRATIVE The description of the standard code This is the only field that can be updated for a standard code ANSI REASON CODE NARRATIVE When the entire list of codes is displayed for a specific Record Type to display the entire narrative for one specific ANSI code 1 Type an S in the S Select field to view the entire narrative for the ANSI code Figure 35 provides an example of the list that displayed for record type A Palmetto GBA Page 60 September 2015 Section 4 Claim Inquiry DDE User s Manual ANSI Standard Codes Selection Inquiry Screen MAP1581 Figure 35 Field descriptions are provided in the table following Figure 34 MAP1581 JM MAC SC HHH UAT 11001 ACMFA891 08 26 15 SC ANSI STANDARD CODES SEL INQUIRY C201534P 17 08 33 RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE TERM DT NARRATIVE MA01 ALERT IF YOU DO NOT AGREE WITH WHAT WE APPROVED FOR THESE MA02 ALERT IF YOU DO NOT AGREE WITH THIS DETERMINATION YOU HAV MA03 111805 IF YOU DO NOT AGREE WITH THE APPROVED AMOUNTS AND 100 OR M MA04 110407 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE
186. layed on the screen as PCTC Professional Component Technical Component This field identifies the indicator that is added to the Comprehensive Outpatient Rehabilitation Facility CORF extract of the Medicare Physician Fee Schedule Supplementary File This is used to identify professional services eligible for the Health Professional Shortage Area HPSA bonus payments This field is only applicable when pricing Critical Access Hospitals CAHs that have elected the optional method Method 2 of payment This is a one position alphanumeric field with up to 40 occurrences The valid values are PC TC HPSA Payment Policy O Physician service codes 1 Diagnostic Tests for Radiology Services 2 Professional component only a Technical component only 4 Global test only codes 5 Incident codes payment of the HPSA bonus may not be made by Medicare for these services when they are provided to hospital inpatients or patients in a hospital outpatient department 6 Laboratory physician interpretation codes T Physical therapy service payment of the HPSA bonus may not be made if the service is provided to either a patient in a hospital outpatient department or to an inpatient of the hospital by an independently practicing physical or occupational therapist 8 Physician interpretation codes payment of the HPSA bonus may be made for certain CPT codes 9 Not applicable concept of PC TC does not apply Note This field is dis
187. liability technical not subject to waiver provisions K Full Provider liability not subject to waiver provisions M Pay per waiver line or partial line N Provider liability line or partial line O Beneficiary liability line or partial line P Open biopsy changed to closed biopsy Q Release with no medical review performed R CWF Common Working File denied but medical review was performed Z Force claim to be re edited by Medical Policy Special Screening 5 Generates systematically from the reason code file to identify claims for which special processing is required 7 Force claim to be re edited by Medical Policy edits in the 5XXXX range but not the 7XXXX range 8 A claim was suspended via an OCE MED review reason 9 Claim has been identified as First Claim Review WAIV IND Identifies whether the Provider has their presumptive waiver status Valid values are Y The Provider does have their waiver status N The Provider does not have their waiver status MR REV URC The Medical Review Utilization Review Committee Reversal field identifies whether an SNF URC Claim has been reversed This indicator can be used for a partial or a full reversal Valid values are Palmetto GBA Page 83 September 2015 Section 5 Claim Entry DDE User s Manual Field Name MD Description P Partial reversal F Full reversal the system reverses all charges and days DEMAND The Medical Review
188. ll default to a 01 except for 90743 with a locality of 00 HCPC Type the five digit HCPC code to view MOD This field identifies Multiple fees for one HCPC code based on the presence or absence of a modifier in this field The default value is blank unless a valid modifier is entered for the HCPC IND HCPC Indicator this field is not used in DDE EFF DT This field identifies the National Drug Code effective date TRM DT This field identifies the National Drug Code termination date PROVIDER This field identifies the identification number of the Alias Provider DRUG CODE This field identifies whether the HCPC is a drug E The HCPC is a drug The HCPC is not a drug EFF DT This field identifies when the change in pricing went into effect MMDDYY format TRM DT This field identifies the termination date for each rate listed for this HCPC EFF Effective Date Indicator This indicator instructs the system to use From Through dates on claims or use the system run date to perform edits for this particular HCPC date Valid values are R Receipt Date F From Date D Discharge Date Note This field is displayed on the screen as E F F OVR The override code instructs system in applying the services to the beneficiary deductible and coinsurance Valid values are 0 Apply deductible and coinsurance Do not apply deductible Do not apply coinsurance Do not apply deductible or coinsurance No n
189. ment Factor This field identifies factor used to adjust the FACTOR capital federal rate based on the applicable wage index ADJUSTED This field identifies the base capital rate LARGE URBAN This field identifies the federal rate applicable to those hospitals located in a large ADD ON urban SMSA BLEND RATIO These fields identify the ratio of the Hospital Specific Rate HSR and the federal HOSP FED rate used to compute capital payments under PPS NEW CAPITAL This field identifies new capital to total capital and is applicable for hospitals being RATIO reimbursed under the hold harmless payment method for capital OLD CAPITAL This field identifies the old capital cost per discharge as provided by the hospital PAYMENT or as provided by the latest filed cost report under capital PPS and is applicable for those hospitals being reimbursed under the hold harmless payment method for capital Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description HOSPITAL This field identifies the capital base period cost per discharge updated to SPECIFIC RATE applicable fiscal year end Federal Hospital TOTAL FEDERAL This field identifies the Total Federal amount AMOUNT TOTAL HOSPITAL This field identifies the Total Hospital amount AMOUNT TOTAL This field identifies the total Federal and Hospital amounts DRG Cost Disclosure Inquiry MAP1785 Field de
190. n Enter the appropriate inpatient code that indicates the priority of the admission Refer to your UB 04 Manual for valid values SRC 15 The source of admission Enter appropriate code indicating the point of origin of the source of this admission Refer to your UB 04 Manual for valid values D HM 16 Enter the time at which the patient was discharged from inpatient care in HHMM format STAT 17 Indicates the patient s status at the ending service date in the period Refer to your UB 04 Manual for valid values COND CODES 18 The condition codes are used to identify conditions relating to this bill that 01 10 28 may affect claim processing up to 30 occurrences Refer to your UB 04 Manual for valid values OCC CDS 31 The Occurrence Codes and Dates field consists of a two digit alphanumeric DATE 01 10 34 code and a six digit date in MMDDYY format Report all appropriate occurrences up to 30 occurrences Refer to your UB 04 Manual for valid values SPANCODES 35 Enter the appropriate Occurrence Span code and Date associated DATES 01 36 beginning From and ending Thru dates defining a specific event relating 10 to this billing period Refer to your UB 04 Manual for valid values FAC ZIP This field identifies the provider s facility ZIP code The entire nine digit ZIP code must be entered and should match the facility s master address in the provider enrollment record usually the facility s physical location DCN
191. n code are manually reviewed EO Change in patient status Palmetto GBA Page 110 September 2015 Section 7 Online Reports DDE User s Manual SECTION 7 ONLINE REPORTS The Online Reports View function allows viewing of certain provider specific reports by the Direct Data Entry Provider The purpose of the reports is to inform the providers of the status of claims submitted for processing and provide a monitoring mechanism for claims management and customer service to use in determining problem areas for providers during their claim submission process As reports are viewed on line it will be necessary to scroll or toggle between the left view Scroll L and the right view Scroll Right Use the F11 key to move to the right and the F10 key to return to the left To access the online reports choose menu selection 04 from the DDE Main Menu The Online Reports Menu will display Figure 55 Online Reports Menu MAP1705 A description of the type of reports that can be viewed is provided following Figure 55 MAP1705 JM MAC SC HHH UAT 11001 ONLINE REPORTS MENU R1 SUMMARY OF REPORTS R2 VIEW A REPORT R3 CREDIT BALANCE REPORT CMS 838 ENTER MENU SELECTION i PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 55 Online Report Menu The most frequently viewed provider reports are the Claims Returned to Provider Report 050 Pending the Processed and Returned Claims Report 201 and the Errors on Initial Bills
192. name of the rendering physician M The middle initial of the rendering physician SC This field identifies the Critical Access Hospital Physician Non Physician specialty code Palmetto GBA Page 73 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 CLAIM ENTRY PAGE 2 LINE LEVEL REIMBURSEMENT This screen displays line item payment information and allows entry of more than two modifiers Access the MAP171A screen Figure 43 by pressing F11 twice on Claim Page 2 MAP1712 INST Claim Entry Claim Page 2 Line Level Reimbursement MAP171A Field descriptions are provided in the table following Figure 43 MAP171A PAGE JM MAC SC HHH UAT 11001 Sc INST CLAIM ENTRY DCN HIC RECEIPT DATE STATUS LOCATION TRAN DT STMT COV DT SERV SERV UTN PGM REV HCPC MODIFIERS DATE RATE TOT UNT COV UNT TOT CHRG ANES CF ANES BV FQGHCADD PC TC IND HCPC TYPE DEDUCTIBLES COINSURANCE ESRD RED VALCD 05 BLOOD CASH WAGE ADJ REDUCED PSYCH HBCF OTHER PAT gt MSP gt ANSI gt PAY HCPC MSP gt OUTLIER gt APC CD PAYER 1 PAYER 2 OTAF DENIAL OCE FLAGS MSP IND 12 3 45 6 7 8 9 ID REIMB PAID REDUCT AMT ANSI PAT LABOR NON LABOR PROV MED PRICER PAY ASC ADJUSTMENT ANSI AMT RTC METHOD IDE NDC UPC GRP CONTR PROCESS COMPLETED PLEASE CONTINUE PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DN PF7 PRE PF8 NXT PF9 UPDT PF10 LT PF11 RT Figure 43 UB 04 Claim Entry Page 2 Line Level Reimbursement UB 04
193. nation REAS Reason Code Indicates the reason for the inquiry DATETIME Date and Time Stamp date and time of the inquiry in Julian date format REQ Requestor ID auto populates Disposition Indicates a condition on a CABLE response Valid values are Code 01 Part A Inquiry approved 02 Part A Inquiry approved 03 Part A Inquiry rejected 20 Qualified approval but may require further investigation 25 Qualified approval 50 Not in file 51 Not in file on CMS batch system 52 Master record housed at another HOST site 53 Not in file in CMS but sent to CMS s alpha reinstate 55 Does not match a master record ER Consistency edit reject UR Utilization edit CR A B crossover edit Cl CICS processing problem SV Security violation MSG Message The verbiage pertaining to the disposition code Palmetto GBA Page 148 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual Field Name Description CORRECT Correct Claim Number Displays the beneficiary s correct HIC number If the HIC entered in the inquiry screen Figure 83 is different than the number in this field this is the number you will use to submit claims NM Corrected Name This field displays the beneficiary s correct name The name in this field will be different only if the name entered in the inquiry Figure 83 screen is not consistent with CMS s record IT Corrected In
194. nd the program ending date both in MMDDYY TERM DATE format Adjustment Reason Code Inquiry Select option 16 from the Inquiry Menu to access the Adjustment Reason Codes Inquiry screen This screen provides an on line access method to identify a two digit adjustment reason code and a narrative description for the adjustment reason code It can also be used to validate the adjustment reason code entered on an adjustment To start the inquiry process type in an adjustment reason code and press ENTER or just press ENTER and a list of adjustment reason codes will be displayed Palmetto GBA Page 50 September 2015 pecnun s cHMImingully EEE EE EA EE DDE Y Sors Manual Adjustment Reason Codes Inquiry Selection Screen MAP1821 Field descriptions are provided in the table following Figure 28 MAP1821 JM MAC SC HHH UAT 11001 SC ADJUSTMENT REASON CODES INQUIRY SELECTION SCREEN MNT CLAIM TYPES I INPATIENT SNF O OUTPATIENT H HOME HEALTH CORF A ALL CLAIMS PLAN CODE REASON CODE S PC RC HC TYPE NARRATIVE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 28 Adjustment Reason Codes Inquiry Selection Screen Field Description CLAIM TYPES Describes the claim types identified for each adjustment reason code PLAN CODE Differentiates between plans Intermediaries that share a processing site The home host site is considered 1 by the system It is the number assigned to the site on the System
195. nformation Each S LOC code is made up of two alpha characters followed by four numeric characters For example P B9997 is a status location code e The first position position a is the claim s current status In this example P indicates that the claim has been paid or partially paid e The second position position b is the claim processing type In the example B indicates batch e The third and fourth positions positions cc are the location of the claim in FISS In the example 99 indicates that the session terminated which essentially means that the processing of the claim is completed e The last two positions positions dd are for additional location information In the example 97 indicates that the provider s claim is final on line A provider may perform certain transactions when there is a specific S LOC code on the claim Other transactions cannot be done at all with certain S LOC codes The following table provides descriptions of the S LOC code components Palmetto GBA Page 2 September 2015 Section 1 Introduction DDE User s Manual FISS S LOC Codes Status Processing Type Driver Location Location Position a Position b Positions cc Positions dd A Good M Manual 01 Status Location 00 Batch Process Inactive O Off line 02 Control 01 Common S Suspense B Batch 04 UB 04 Data 02 Adj Orbit M Manual Move 05 Consistency l 10 Inpatient P Paid Partial Pay 06 Co
196. nsistency Il 11 Outpatient R Reject 15 Administrative 12 Special Claims D Deny 25 Duplicate 13 Medical Review T 2 RTP 30 Entitlement 14 Program Integrity U Retto PRO 35 Lab HCPC 16 MSP 40 ESRD 18 Prod QC 50 Medical Policy 19 System Research 55 Utilization 21 Waiver 60 ADR 65 Non DDE Pacemaker 63 HHPPS Pricer 66 DDE Pacemaker 65 PPS Pricer 67 DDE Home Health 70 Payment 96 Payment Floor 75 Post Pay 97 Final Online 80 MSP Primary 98 Final Off line 85 MSP Secondary 99 Final Purged 90 CWF Awaiting CWF 99 Session Term Response AA ZZ User defined 22 64 User defined 68 79 User defined AA ZZ User defined Document Control Number DCN The DCN number is located on the remittance advice This number must be used with adjustment cancellation bills Field Definition Position 1 1 Century Code Code used to indicate the century in which the DCN was established Valid values include 1 21900 1999 2 22000 2 9 Year The last two digits of the year during which the claim was entered This is System generated 4 6 Julian Date Julian days corresponding to the calendar entry date of the claim This is system generated 7 10 Batch Primary sequencing field beginning with 0000 and ending with 9999 This Sequence is system generated with automated DCN assignment 11 12 Claim Secondary sequencing field beginning with 00 and end
197. o provide additional information to the Waiver Employee to assist that individual with claim finalization The remarks field is also used for Providers to furnish justification of late filed claims that override the Medicare contractor s existing reason code for timeliness The following information must be entered on the first line Additional information may be entered on the second and subsequent lines of the remarks section for further justification Select one of the following reasons and enter the information exactly as it appears below Justify MSP involvement Justify SSA involvement Palmetto GBA Page 93 September 2015 Section 5 Claim Entry DDE User s Manual Justify PRO Review involved Justify Other involvement Attachments The following provides information on attachments 47 Pacemaker No longer used 48 Ambulance Not used 40 Therapy Not used 41 Home Health Not used 58 HBP Claims Med B Not used E1 ESRD Not used ANSI CODES Identifies the general category of payment adjustment Used for claims GROUP submitted in an ANSI automated format only ADJ Claim adjustment standard reason code that identifies appeals codes for REASONS inpatient or outpatient APPEALS Identifies ANSI appeals codes for inpatient or outpatient UB 04 CLAIM ENTRY PAGE 5 Page five of the UB 04 Claim Entry screen Figure 47 is used to enter a patient s payer in
198. o change hospices during a benefit period that submits claims to a different contractor REVOCATION Revocation Indicator Indicates if a beneficiary has revoked hospice benefits for IND the period Valid values are 0 Beneficiary has not revoked hospice benefits 1 Beneficiary has revoked hospice benefits Palmetto GBA Page 129 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 3 Field descriptions for Page 3 of the HIQA screen are provided in the table following Figure 68 HIQACOP INQUIRY REPLY IP REC HOSPICE DATE PERIOD 014 OWNER CHANGE 014 PERIOD 013 OWNER CHANGE 013 START DATE1 TERM DATE1 PROV1 INTER 1 DOEBA DATE DOLBA DATE DAYS USED START DATE2 PROV2 INTER2 REVOCATION IND PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 68 CWF Part A Inquiry Reply Screen Page 3 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code PAP PAP Risk Indicator Valid values are 1 Yes 2 No PAP DATE Date PAP performed MAM Mammo Risk Indicator Valid values are 1 Yes 2 No TECH PROF _ This is the date that the technician professional claims were presented for x rays used f
199. o not deduct days for payment made by another primary payer N C Indicates the total number of non covered days Enter the total number of non covered days in the billing period e Enter the total number of covered days during the billing period within the From and Through dates in UB 04 X REF 6 Statement Covers Period These days are not covered Medicare payment days on the cost report and the beneficiary will not be charged utilization for Medicare Part A Services e The reason for non coverage should be explained by occurrence codes UB 04 X REFs 31 34 and or occurrence span code UB 04 X REF 35 96 Provide a brief explanation of any non covered days not described via occurrence codes in UB 04 X REF 80 Remarks Show the number of days for each category of non covered days e g 5 leave days e Day of discharge or death is not counted as a non covered day Do not deduct days for payment made by another primary payer CO Co Insurance Days are the inpatient Medicare hospital days occurring after the 60 day and before the 91 day Enter the total number of inpatient or SNF co insurance days Palmetto GBA September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description LTR Lifetime Reserve Days This field is only used for hospital inpatient stays Enter the total number of inpatien
200. o submit claims for If the Medicare Oscar number is not changed for your sub units the claims will be processed under the incorrect Oscar number SV Suppress View This field allows a claim to be suppressed UB FORM Identifies the type of claim to be processed All claims must be entered on the same form type Valid values are 9 UB 92 A UB 04 NPI 56 This field identifies the National Provider Identifier number TRANS HOSP Transferring Hospice Provider Displays the identification number of the PROV institution that rendered services to the beneficiary patient System generated for external operators that are directly associated with one provider This number is assigned by CMS This is a 13 digit Palmetto GBA Page 67 September 2015 Section 5 Claim Entry Field Name PROCESS NEW HIC UB 04 X Ref 60 DDE User s Manual Description Identifies when the incorrect beneficiary health insurance claim number is present and then the correct health insurance claim number can be keyed Not applicable on new claim entries Valid values include Y Incorrect HIC is present E The new HIC number is in a cross reference loop orthe new HIC entered is cross referenced on the Beneficiary file and this cross referenced HIC is also cross referenced The chain continues for 25 HIC numbers S The cross referenced HIC number on the Beneficiary file is the same as the original HIC number on the c
201. o the hard copy claims for action on EMC claims HC PRO ST LOC Hardcopy Peer Review Organization status and location code for hard copy paper and peer review organization claims This is the path DDE will follow PP LOC This field identifies the five position alphanumeric post pay location of B75XX CC IND The clean claim indicator instructs the system whether to pay interest or not if applicable TPTPA Tape to tape Flag indicator for Part A which controls the flow of the claim to CWF to the provider via the remittance advice to the PS amp R system and for counting the claim for workload purposes B Tape to tape Flag indicator for Part B NPCD A The Non pay code for Medicare Part A which identifies the reason for Medicare s decision not to make payment B The Non pay code for Medicare Part B which identifies the reason for Medicare s decision not to make payment HD CPY A This field instructs the system to generate a specific hardcopy document during the claim process on a Medicare Part A claim B This field instructs the system to generate a hardcopy document during the claim process on a Medicare Part B claim NB ADR This field identifies the number of times an Additional Documentation Request ADR form is to be generated Identified by a 1 or a 2 CAL DY This field identifies the number of calendar days a claim is to orbit after the generation of an ADR C L This field iden
202. oe 66 UB 04 Claim Bnitry P ge 2 iere rhet creed Eee ipee certas be eon Eee ee ob Eden ene EUR 70 UB 04 Claim Entry Page 2 Additional NPI Lines esee 72 UB 04 Claim Entry Page 2 Line Level Reimbursement eeeeeeeee 74 UB 04 Claim Entry Page 2 Additional Detail eese 80 UB 04 Claim Entry Page 3 sitet n Lm redes Lise eere PR CE EE TR ERE ER TER a e EH EH R EE Cp e PR ca 88 U B 04 Clatm EBiitry Dage 4 ante ERR dice nene oda ton ane 92 UB 04 Claim Entry Page 5 ener enne nene nese tenete tenente tnter enne 94 UB 04 Claim Entry Page 6 nennen ren nennen nest a tentent nnne 96 Roster Bill Pir T Em 98 ESRD CMS 382 botm 2 cited abe terae eee CD a EE LEE pde EE TER RE EE EE CAREER P niet bae 100 Palmetto GBA Pagei September 2015 DDE User s Manual Table of Contents SECTION 6 CLAIM CORRECTION 103 Online Claims Corrector e aree E A PERENNE ERR E Celeb ERU E O LS E E e aaa 103 Claim Summary Inquiry repre terere eere abro re ber ee EF ee reet Hop Ped e EA ERE ENEs 103 Claims Correction Processing Tips eseesseeseeeseeeseeeeeeeen rennen eren nennen tenerent nnne 105 Correcting Revenue Code Lines eti coeno opone teen ges ra EEE ipsae nE E RSEN NERE 105 RIP Selection Process orn rnnt teen ee tenet peteret ipe se Ea AE i EE Puede EREE 106 Suppressmg RTP C aims niri erc rad Ha ED e E o Hee Ree eeu ee E Eoo de 107 Claims
203. of the date of birth and century indicator APPROVED LOS The approved length of stay LOS is necessary for the Pricer to determine whether day outlier status is applicable in non transfer cases and in transfer cases to determine the number of days for which to pay the per diem rate Normally Pricer covered days and approved length of stay will be the same However when benefits are exhausted or when entitlement begins during the stay Pricer length of stay days may exceed Pricer covered days in the non outlier portion of the stay COV DAYS The number of Medicare Part A days covered for this claim Pricer uses the relationship between the covered days and the day outlier trim point of the assigned DRG to calculate the rate Where the covered days are more than the approved length of stay Pricer may not return the correct utilization days The CWF host system determines and or validates the correct utilization days to charge the beneficiary LTR DAYS The number of lifetime reserve days This 2 digit field may be left blank Palmetto GBA Page 33 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description PAT LIAB The Patient Liability Due identifies the dollar amount owed by the beneficiary to cover any coinsurance days or non covered days or charges The information displayed under the RETURNED FROM GROUPER on this screen will be the same as the data returned after
204. of the claim 5 To back out without transmitting the adjustment press F3 Any changes made to the screens will not be updated 6 Press F9 to update enter the claim into DDE for reprocessing and payment consideration Claims being adjusted will still show on the claim summary screen Always check the inquiry claim summary screen option 12 to affirm location of the claim being adjusted 7 Check the remittance advice to ensure that the claim adjusted properly CLAIM VOIDS CANCELS Using the Claim Cancels option providers can cancel previously paid finalized claims After a claim is finalized it is given a status location code beginning with the letter P and is recorded on the claim status inquiry screen A claim cannot be voided canceled unless it has been finalized and is reflected on the remittance advice Providers must be very careful when creating cancel claims If you go into the cancel option be certain that you want to cancel the claim If you do not want to cancel the claim after you have accessed it hit F3 to go back to the claims correction menu Once you hit F9 the cancel will be created and process through the system This will cause payment to be taken back unnecessarily Once a claim has been voided canceled no other processing can occur on that bill Important notes on cancels All bill types can be voided except one that has been denied with full or partial medical denial Donotcancel TOB XXP PRO adj
205. on Response Code that is returned from the NCD edits Valid values include Set to space for all lines on resubmitted RTP D claims default value 0 The HCPCS Diagnosis code matched the NCD edit table pass criteria The line continues through the system s internal local medical necessity edits 1 The line continues through the system s internal local medical necessity edits because the HCPCS code was not applicable to the NCD edit table process the date of service was not within the range of the effective dates for the codes the override indicator is set to Y or D or the HCPCS code field is blank 2 None of the diagnoses supported the medical necessity of the claim list 3 codes but the documentation indicator shows that the documentation to support medical necessity is provided The line suspends for medical review 3 The HCPCS Diagnosis code matched the NCD edit table list ICD 9 CM deny codes list 2 codes The line suspends and indicates that the service is not covered and is to be denied as beneficiary liable due to non coverage by statute 4 None of the diagnosis codes on the claim support the medical necessity for the procedure list 3 codes and no additional documentation is provided This line suspends as not medically necessary and will be denied 5 Diagnosis codes were not passed to the NCD edit module for the NCD HCPCS code The claim suspends and the FI will RTP the claim NCD Nati
206. onal Coverage Determination Number This field identifies the NCD number associated with the beneficiaries claim denial OLUAC Identifies the original line user action code It is only populated when there is a line user action code and a corresponding denial reason code in the Benefits Savings portion of claim page 32 LUAC The Line User Action Code identifies the cause of denial for the revenue line and a reconsideration code The denial code first position must be present in the system and pre defined in order to capture the correct denial reason The values are equal to the values listed for User Action Codes The reconsideration code second position has a value equal to R indicating to the system that reconsideration has been performed Palmetto GBA Page 86 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name x Ref Description For the Revenue Code Total Line 0001 the system generates a value in the first two line occurrences of the LUAC field These values indicate the type of total amount displayed on the total non covered units and non covered charges for the revenue code line 0001 only on MAP171D These values do not apply to this field for any other revenue code line other than 0001 Valid values are 1 LUAC lines present on MAP171D 2 Non LUAC lines present on MAP171D NON COV Non Covered Units identifies the number of days visits that are being UNT denied Denied days
207. or mammography screening IMMUNO Indicates Medicare transplant surgery coverage available to the beneficiary Valid TRANSPLANT values are DATA COV IND 1 Space No Coverage 2 Transplant Coverage TRANS IND Transplant Type Indicator Indicates the type of transplant surgery performed on the beneficiary Valid values are 1 Allograft bone marrow transplant from another person 2 Autograft bone marrow transplant from beneficiary H Heart transplant K Kidney transplant L Liver transplant DISCH DATE Discharge Date The date the beneficiary was discharged from a hospital stay during which the indicated transplant occurred HOSPICE DATA Indicates if the beneficiary elected the Medicare hospice benefit START DATE1 The elected start date of a beneficiary s period of hospice coverage Palmetto GBA Page 130 September 2015 Section 8 Health Insurance Query DDE User s Manual Field Name Description TERM DATE 1 Indicates the termination of the first hospice benefit period May be listed as the end of the benefits for the hospice period indicated or the revocation of hospice benefits PROV1 First Provider first provider the beneficiary has elected for hospice benefits This is the assigned Medicare provider number INTER1 First Intermediary Number Indicator as to the Medicare contractor that is processing the Hospice claim DOEBA Date of earliest billing action DOLBA D
208. ory Surgical Center HRR Hospital Readmission Reduction ANSI American National Standards HSA Health Service Area Institute HSP Hospital Specific Payment HSR Hospital Specific Rate CAH Critical Access Hospital ICD Internal Classification of Diseases CARC Claim Adjustment Reason Code ICN Internal Control Number CLIA Clinical Laboratory Improvement IDE Investigational Device Exemption Amendments of 1988 IEQ Initial Enrollment Questionnaire CMG Case mix Group IME Indirect Medical Education CMHC Community Mental Health Center IPPS Inpatient Prospective Payment CMN Certificate of Medical Necessity System CMS Centers for Medicare amp Medicaid IRF Inpatient Rehabilitation Facility Services IRS Internal Revenue Service CO Contractual Obligation CORF Comprehensive Outpatient Rehabilitation Facility CPT Current Procedural Terminology LGHP Large Group Health Plan CWF Common Working File LOS Length of Stay LTR Lifetime Reserve days DCN Document Control Number METRIS eee DDE Direct Data Entry MA Medicare Advantage Plan DME Durable Medical Equipment MAC Medicare Administrative Contractor DRG Diagnosis Related Grouping MCE Medicare Code Editor DSH Disproportionate Share Hospital MR Medical Review ne eee MSA Metropolitan Statistical Area EDI Electronic Data Interchange MSN Medicare Summary Notice EGHP Employer Group Health Plan MSP Medicare Secondary Payer EMC Electronic Media Claims EN eee eee ERA Electronic Remittance Ad
209. ot meaningful users of EHR This is an eleven digit field in 9999999 99 format DRG Cost Disclosure Inquiry MAP1782 Field descriptions are provided in the table PVDR D DT DRG NUMBER OPERATING CAPITAL OPERATING CAPITAL OPERATING CAPITAL NEW PROVIDER RELATIVE WEIGHT OPERATING PAYMENT following Figure 20 JM MAC VA WV UAT 11003 DRG COST DISCLOSURE INQUIRY VERSION FROM DT IME RATIO THRU DT XIX SSI RATIO RATIO DSH FACTOR IME FACTOR URBAN RURAL NUMBER OF BEDS LOW VOL PYMNT DISPROPORTIONATE SHARE OUTLIER DAY CUTOVER OPERATING PAYMENT DSH IME CAPITAL PAYMENT ALOS DSH IME CAPITAL PAYMENT TOTAL PAYMENT PLEASE ENTER DATA PRESS PF3 FOR DRG PPS INQUIRY Figure 20 DRG Cost Disclosure Inquiry Field Name Description PVDR Displays the provider number VERSION Contains the provider name FROM DT D DT The date for which the DRG information is being selected MMDDYY Format The From Date MMDDYY Format THRU DT The Thru Date MMDDYY Format Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description DRG NUMBER Pricer version number five position alphanumeric field DSH FACTOR Operating disproportionate share factor five digit field in 9 9999 format OPERATING CAPITAL IME FACTOR Operating indirect medical education factor five digit field in 9 9999 format OPERATING CAPITAL IME R
210. otal Units and Covered Units To delete a revenue code line type four zeros over the revenue code and press ENTER or type D in first position of field hit the HOME key and then press ENTER To insert a revenue code line type it at the bottom of the list and press ENTER DDE will automatically re sort the lines Be sure to adjust the totals on the 001 revenue code line if already entered F2 a jump key when placed on a revenue code on MAP171D allows you to scroll to the same revenue code line on MAP171D A total of 13 revenue code lines are available per screen To enter additional revenue lines press F6 to page forward and F5 to page back If you delete or insert a revenue code line the system will re sort the lines There are a total of 450 revenue code lines Thus only 449 revenue code lines can be entered on a single claim plus the 001 revenue code line Palmetto GBA Page 70 September 2015 Section 5 Claim Entry DDE User s Manual INST Claim Entry Screen Page 2 MAP1712 Field descriptions are in the table Following Figure 41 MAP1712 PAGE JM MAC SC HHH UAT 11001 SC INST CLAIM ENTRY REV CD PAGE HIC TOB S LOC PROVIDER UTN PROG TOT COV SERV RED CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND PROCESS COMPLETED PLEASE CONTINUE PRESS PF2 171D PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF9 UPDT PF11 RIGHT Figure 41 UB 04 Claim Entry Revenue Screen
211. owing designations GL Great Lakes GL Great Lakes GL Great Lakes GW Great West GW Great West GW Great West KS Keystone KS Keystone KS Keystone APP DATE Date the beneficiary was admitted to the hospital in MMDDYY format This field is not required However entering a date will allow for the most recent information to be provided REASON CODE Indicates the reason for the inquiry Valid codes are 1 Status Inquiry 2 Inquiry relating to an admission A 1 is automatically inserted in this field by the system Change this only if applicable Palmetto GBA September 2015 Page 147 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Page 1 Field definitions and completion requirements are provided in the table following Figure 83 UNCONDITIONAL ACCEPT PF1 INQ SCREEN PF3 CLEAR END PF8 NEXT Figure 83 CWF Part A Inquiry Reply Screen Page 1 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code IN Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA PN Provider Number The agency s Medicare provider number APP Applicable Date Used for spell determi
212. owing points Only one date of service per roster page A maximum of ten patients per roster page may be reported on a DDE roster page Vaccine Roster For Mass Immunizers Screen MAP1681 Field descriptions are provided in the table following Figure 49 JM MAC SC HHH UAT 11001 SC VACCINE ROSTER FOR MASS IMMUNIZERS RECEIPT DATE OSCAR DATE OF SERV TYPE OF BILL NPI TAXO CD FAC ZIP REVENUE CODE HCPC CHARGES PER BENEFICIARY PATIENT INFORMATION HIC NUMBER LAST NAME FIRST NAME INIT BIRTH DATE SEX ADMIT DATE ADMIT TYPE ADMIT DIAG PAT STATUS ADMIT SRCE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 49 DDE Roster Bill Page Field Name Description RECEIPT DATE The system date that the claim was received by the Medicare contractor Palmetto GBA Page 98 September 2015 Section 5 Claim Entry DDE User s Manual Field Name Description OSCAR The identification number of the institution that rendered services to the beneficiary patient Note The system will auto fill the Medicare provider number used when logging on to the DDE system If your facility has sub units SNF ESRD Home Health Inpatient etc the Medicare OSCAR number must be changed to reflect the OSCAR number for which you wish to submit claims If the Medicare OSCAR number is not changed for your sub units the claims will be processed under the incorrect OSCAR number DATE OF The date the service was rendered to the beneficiary in MMDDYYY
213. pe of TRM DT Bill Valid values are Y Yes N No HCPC Inquiry Select option 14 from the Inquiry Menu to access the HCPC Inquiry screen This screen displays the current rate utilized to price specific outpatient services identified by a HCPCS code The FISS does pre payment processing of HCPCS codes for laboratory services but Radiology Ambulatory Surgery Center ASC Durable Medical Equipment DME and Medical Diagnostics HCPC service codes are processed post payment To start the inquiry process enter the HCPCS code and the Locality code then press ENTER HCPC Inquiry Screen MAP1771 Field descriptions for the HCPC Inquiry screen are provided in the table following Figure 26 MAP1771 JM MAC SC HHH UAT 11001 HCPC INFORMATION INQUIRY CARRIER LOC HCPC MOD IND EFF DT TRM DT PROVIDER DRUG CODE ANES T M PC BASEY S TC VAL P I ALLOWABLE REVENUE CODES EOFOC EFF TRM FYVYEPA DATE DATE FREHT HCPC DESCRIPTION PROCESS COMPLETED PLEASE CONTINUE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 26 HCPC Inquiry Screen Palmetto GBA Page 46 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description CARRIER The Medicare contractor identification number LOC The area or county where the provider is located This field accepts as a valid value only the six locality codes entered on the Provider File and 01 If a HCPC does not exist for the specific locality the system wi
214. pe of insurance e g insurance or indemnity Palmetto GBA Page 143 September 2015 Section 8 Health Insurance Query DDE User s Manual Field Name Description EMPLOYER These fields are not utilized in DDE INFORMATION NOTE HIQA Page 16 Figure 81 reflects that it is Page 16 of 19 The total number of pages following Page 15 for an HIQA record will vary If as in this example a beneficiary has more than one valid MSP record on the CWF the pages that follow page 16 will provide the remaining insurance plans and information in the same layout as HIQA Page 16 Palmetto GBA Page 144 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual SECTION 9 HEALTH INSURANCE QUERY FOR HHA The Health Insurance Query for HHAs HIQH allows different types of institutional providers to inquire about a beneficiary and receive an immediate response about their Medicare eligibility based on available claims data Since beneficiaries often move from home health to hospice care both HHAs and hospices can employ HIQH as their single CWF inquiry transaction HIQH which includes the information made available in HIQA gives Medicare providers direct access to the CMS s CWF Host database Providers may query a Beneficiary s Master Record The beneficiary s record contains Medicare entitlement hospice benefit information health maintenance organization HMO information and other payer information Eac
215. pell of Illness Number This number reflects the current home health spell of Palmetto GBA Page 131 September 2015 Section 8 Health Insurance Query DDE User s Manual Field Name Description illness QUALIFYING Qualifying Stay Indicator This is a numeric field used to identify a qualifying A B IND split hospitalization Valid values are 0 No 1 Yes PART A VISITS The number of Part A visits remaining in the benefit period Medicare Part A pays for REMAINING the first 100 visits if a patient has a qualifying hospital stay and if a patient is admitted to home health within 14 days of discharge Medicare Part B pays for the remaining visits In addition Medicare Part B pays for all visits if there is no qualifying hospital stay the patient must have Medicare Part B for Part B to reimburse for the services If a beneficiary has Medicare Part A only then Part A will pay for all of their services EARLIEST The date of the first bill submitted during the benefit period BILLING LATEST BILLING The date of last bill submitted during the benefit period PARTB VISITS The number of visits reimbursed by Medicare Part B APPLIED HIQA Page 5 Field descriptions for Page 5 of the HIQA screen are provided in the table PF1 INQ SCREEN following Figure 70 INQUIRY REPLY PF3 CLEAR END PF8 NEXT Figure 70 CWF Part A Inquiry Reply Screen Page 5 Field Name Description
216. played on the screen as PC TC ANES BASE VAL Identifies the anesthesia base values Palmetto GBA Page 48 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description TYP This field identifies whether other HCPCS originated from the Medicare Physician Fee Schedule MPFS database files and the fee rate Valid values are M Originated from MPFS database files Did not originate from the MPFS database files Note This field is displayed on the screen as T Y P MSI This field identifies the Multiple Service Indicator MSI Note This field is displayed on the screen as M S ALLOWABLE Billable UB 04 revenue codes for the HCPC entered The fourth digit of the REVENUE CODES revenue code may be stored with an X indicating it is variable By leaving this field blank the system will allow a HCPC on any revenue code HCPC Narrative for the HCPC DESCRIPTION Diagnosis amp Procedure Code Inquiry ICD 9 Select option 15 from the Inquiry Menu to access the ICD 9 CM Code Inquiry screen This screen displays an electronic description for the ICD 9 CM Codebook This screen should be used as reference for ICD 9 CM code s to identify a specific diagnosis code or inpatient surgical procedure code for a related bill To inquire about an ICD 9 CM diagnosis code type the three four or five digit code in the STARTING ICD9 CODE field If more than one
217. plicable Plan Data ID CD Plan Identification Code This field identifies the Plan Identification code for beneficiaries who are enrolled in a Medicare Advantage MA Plan otherwise known as a Medicare HMO plan This is a five position alohanumeric field This field occurs three times The structure of the identification number is Position 1 H Position 2 amp 3 State Code Position 4 amp 5 Plan number within the state OPT CD This field identifies whether the current Plan services are restricted or unrestricted Valid values are Unrestricted Cost based plans 1 Medicare contractor to process all Part A and B provider claims 2 Plan to process claims for directly provided service and for services from Providers with effective arrangements Restricted Risk based Plans A Medicare contractor to process all Part A and B provider claims B Plan to process claims only for directly provided services C Plan to process all claims EFF DT The effective date for the Plan benefits CANC DT The termination date for the Plan benefits Hospice Data PERIOD Specific Hospice election period Valid values are 1 The first time a beneficiary uses Hospice benefits 2 The second time a beneficiary uses Hospice benefits 1ST DT First Hospice Start Date in MMDDYY format of the beneficiary s effective period 1 4 with the Hospice Provider PROVIDER Identifies the hospice s six digit Medicare provider numbe
218. r If Medicare is the primary payer enter Medicare on line A Enter Medicare indicates that the hospital developed for other insurance and determined that Medicare is the primary payer If there are payer s of higher priority than Medicare the claim must be submitted by another electronic software MSP claims cannot be submitted or corrected in DDE OSCAR 51A This field will auto populate with the Oscar Number assigned to the B C provider RI 52A The Release of Information Certification Indicator indicates whether the B C provider has on file a signed statement permitting the provider to release data to other organizations in order to adjudicate the claim AB 53A The Assignment of Benefits Certification Indicator shows whether the B C provider has a signed form authorizing the third party payer to pay the provider EST AMT DUE 55 A Not applicable B C DUE FROM The Due From Patient field is for outpatient services only Enter the amount PATIENT the provider has received from the patient toward payment SERV FAC NPI Service Facility National Provider Identifier NPI This field is used to enter the facility NPI of where the services were provided when other than the billing provider This is a ten digit field MEDICAL 3b Alphanumeric field used to enter patient s Medical Record Number RECORD NBR COST RPT The Cost Report Days identify the number of days claimable as Medicare DAYS patient d
219. r INTER Identifies the Medicare contractor number for the hospice provider OWNER The Change of Ownership Start Date field will display the start date of a change CHANGE ST DT of ownership within the period for the first provider PROVIDER The number of the Medicare hospice provider INTER The Medicare contractor number for the hospice Provider 2ND ST DT A 6 character field that identifies the start date for each 2nd hospice period 1 4 PROVIDER Identifies the hospice s Medicare provider number INTER Identifies the Medicare contractor number for the hospice provider TERM DT A 6 digit numeric field that identifies each termination date for hospice services for this hospice Provider 1 4 OWNER Displays the start date of a change of ownership within the period for the second Palmetto GBA Page 13 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description CHANGE ST DT provider PROVIDER Identifies the hospice s Medicare provider number INTER Identifies the Medicare contractor number for the hospice provider 1ST BILL DT A 6 digit numeric field in MMDDYY format that identifies the date of each earliest hospice bill LST BILL DT A 6 digit numeric field in MMDDYY format that identifies each most recent hospice date DAYS BILLED A 3 digit numeric field that identifies the cumulative number of days billed to date for the beneficiary under each hospice election
220. rd can only be reset by the user with this process once in a 24 hour period Palmetto GBA Page 8 September 2015 Section 3 Main Menu DDE User s Manual SECTION 3 MAIN MENU MAP1701 JM MAC SC HHH UAT 11001 MAIN MENU INQUIRIES CLAIMS ATTACHMENTS CLAIMS CORRECTION ONLINE REPORTS ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 4 The Main Menu The DDE Online system includes the Main Menu Figure 4 that displays after completing the logon procedure Each menu option from the Main Menu displays a sub menu for that option The Inquiries 01 Claims Attachments 02 Claims Correction 03 sub menus and Online Reports 04 are explained in the following sections Palmetto GBA Page 9 September 2015 Section 4 Claim Inquiry DDE User s Manual SECTION 4 CLAIM INQUIRY The system will automatically enter your provider number into the PROVIDER field If the facility has multiple provider numbers you will need to change the National Provider Identifier NPI number to inquire or input information TAB to the NPI field on the respective screen and type in the appropriate number To access the Inquiry Menu select option 01 from the Main Menu THE INQUIRY MENU MAP1702 INFORMATION ON EACH OF THE INQUIRY MENU OPTIONS FOLLOWS MAP1702 JM MAC SC HHH UAT 11001 INQUIRY MENU BENEFICIARY CMWF 10 ZIP CODE FILE 19 DRG PRICER GROUPER OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY CLAIM CO
221. riod Prior Benefit Period Data LST BILL DT FRST BILL DT The date of the earliest billing action in the current benefit period The date of the latest billing action in the current benefit period HSP FULL DAYS The number of regular hospital full days the beneficiary patient has remaining in the current benefit period HSP PART DAYS SNF FULL DAYS the current benefit period The number of hospital coinsurance days the beneficiary patient has remaining in The number of SNF full days the beneficiary patient has remaining in the current benefit period SNF PART DAYS The number of SNF coinsurance days the beneficiary patient has remaining in the current benefit period INP DED REMAIN The amount of inpatient deductible remaining to be met by the beneficiary patient for the benefit period BLD DED PNTS The number of blood deductible pints remaining to be met by the beneficiary patient for the benefit period Current B YR The most recent Medicare Part B year in YY format CASH The remaining Part B cash deductible BLOOD The remaining Part B blood deductible pints PSYCH The remaining psychiatric limit PT The physical therapy dollars remaining OT The occupational therapy dollars remaining Prior B YR The prior Medicare Part B year in YY format CASH The Part B cash deductible remaining to be met in the prior year BLOOD The Part B blood deduc
222. roll Right View Field descriptions are provided in the table following Figure 62 MAP1661 JM MAC VA WV UAT 11003 ACMMAQ51 08 28 15 REPORT VIEW INQUIRY C201534P 17 53 56 REPORT FREQUENCY W SCROLL KEY PAGE SEARCH REPORT 201 003 PAGE 1 CYCLE DATE 8 21 1 S FREQUENCY WEEKLY BLUE CROSS CODE NPI PROVIDER NUMBER FROM THRU ADJ LAST SUB SUSP TOTAL NAME DATE DATE IND TRAN IND TYPE CHARGES ADS 5 05 15 05 05 15 06 15 15 P SUSP 4 000 00 PAT CONTROL NBR 6 11 15 06 11 15 07 27 15 P SUSP 4 000 00 PAT CONTROL NBR 7 04 14 07 04 14 06 10 15 P SUSP 150 00 PAT CONTROL NBR CWFD SUSP CHF DELAYED SUSPENSE CLAIMS COUNT 0 3 TOTAL CHARGES 0 00 8 150 00 8 150 00 ADJUSTMENTS COUNT 0 0 TOTAL CHARGES 0 00 0 00 0 00 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF10 LEFT Figure 62 201 Pended Processed and Returned Claims Scroll Right View Palmetto GBA Page 117 September 2015 Section 7 Online Reports DDE User s Manual Field Name Description Scroll Left REPORT The unique number assigned to the Summary of Pending Claims Other report FREQUENCY The frequency under which the report is run Valid values are D Daily W Weekly or M Monthly SCROLL Indicates which side of the report you are viewing Scroll L is the left side of the report and Scroll R is the right side Press the F11 and F10 keys to move right and left
223. rom and through dates Verify that the type of bill TOB is the same as the TOB on the claim you originally submitted If not TAB to the TOB field and enter the first two digits of the TOB for the claim you are trying to retrieve f you still cannot find the claim back out of Claims Correction press F3 all the way to the Main Menu Choose Inquiry option 01 then Claims option 12 and select the claim Check the Palmetto GBA Page 104 September 2015 Section 6 Claim Correction DDE User s Manual status location S LOC Only claims in status location T B9997 can be corrected Status locations that cannot be corrected include P B9997 This claim has paid An adjustment is required in order to change a paid claim P 09998 This claim was paid but due to its age it has been moved to off line history Timeliness of filing will not allow you adjust this claim P B9996 This claim is waiting to be released from the 14 day payment floor not showing on the RA No correction allowed R B9997 This claim was rejected Submit a new claim or an adjustment D B9997 This claim was denied and may not be corrected or adjusted CLAIMS CORRECTION PROCESSING TIPS The Revenue Code screen has multiple sub screens If you have more Revenue Codes than can fit on one screen press F6 to go the next sub screen Press F5 to go back to the previous screen You can also get from page to page by entering the page number in
224. rride code D Denied for the reason code on the line R Rejected for the reason code on the line MED TEC Medical Technical Denial Indicator This field identifies the appropriate Medical Technical Denial indicator used when performing the medical review denial of a line item Valid values include A Home Health only not intermittent care technical and waiver was applied B Home Health only not homebound technical and waiver was applied C Home Health only lack of physicians orders technical deletion and waiver was not applied D Home Health only Records not submitted after the request technical deletion and waiver was not applied M Medical denial and waiver was applied S Medical denial and waiver was not applied T Technical denial and waiver was applied Palmetto GBA Page 87 September 2015 Section 5 Claim Entry DDE User s Manual i UB 04 eem Field Name X Ref Description U Technical denial and waiver was not applied ANSI ADJ The data for this ANSI Adjustment Reason Code field is from the ANSI file housed as the second page in the Reason Code file The ANSI codes that appear on the line item can be replaced with a new code and the system processes the denial with the entered code The ANSI code is built off the denial code used for each line item Each denial code must be present on the Reason Code file to assign the ANSI code to the denial screen This code will occur once
225. rs this field is blank First Line Of Data HIC Patient s health insurance claim number as it was originally typed Palmetto GBA Page 43 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description PROV MRN Medicare provider number Medical Record Number assigned to the facility by CMS MRN USED IN Claims Correction mode S LOC The status location code assigned to the claim by the FISS TOB The type of facility bill classification and frequency of the claim in a particular period of care ADM DT The admission date on the claim FRM DT The From Date on the claim THRU DT The Through Date on the claim REC DT The date the claim was received in the FISS Second Line Of Data SEL LAST NAME claim inquiry screen Type an S under this field to the left of a specific claim to select that claim Press ENTER to display detailed claim information for the claim you selected See the Claim Entry section of the DDE manual for descriptions of the fields on the entire The beneficiary s last name FIRST INIT The beneficiary s first initial TOT CHG The total charges billed on the claim PROV REIMB The provider s reimbursement amount This field is signed to indicate positive or negative amounts PD DT The date the claim was paid partially paid or processed CAN DT The date the claim was canceled REAS Reason code assigned by the FISS ref
226. rt B benefits entitlement date in MMDDYY format TERM DT Termination date for Part B benefits in MMDDYY format PRI ENT DT Prior entitlement date for Part B benefits in MMDDYY format TERM DT Prior termination date for Part B benefits in MMDDYY format LIFE RSRV Number of lifetime reserve days remaining 00 60 PSYCH Number of lifetime psychiatric days available 000 190 Current Benefit Period Data FRST BILL DT The date of the earliest billing action in the current benefit period in MMDDYY format LST BILL DT The date of the latest billing action in the current benefit period in MMDDYY format HSP FULL DAYS The number of regular hospital full days the beneficiary patient has remaining in the current benefit period HSP PART DAYS The number of hospital coinsurance days the beneficiary patient has remaining in the current benefit period Palmetto GBA September 2015 Section 4 Claim Inquiry Field Name SNF FULL DAYS DDE User s Manual Description The number of SNF full days the beneficiary patient has remaining in the current benefit period SNF PART DAYS The number of SNF coinsurance days the beneficiary patient has remaining in the current benefit period INP DED REMAIN BLD DED PNTS for the benefit period The amount of inpatient deductible remaining to be met by the beneficiary patient The number of blood deductible pints remaining to be met by the beneficiary patient for the benefit pe
227. s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code SUBSCRIBER This field identifies the name of the policy holder of the primary plan NAME POLICY NUM This field identifies the policy number of the primary plan EFF DATE Effective Date This field identifies the date the coverage of the primary plan began TRM DTE Termination Date This field identifies the date the coverage of the primary plan ended or was terminated PATIENT REL Patient Relationship This field identifies the relationship of the subscriber to the beneficiary MSP CODE Medicare Secondary Payer Source Code This field identifies the MSP source code e g disability working aged liability etc Insurer Information NAME This field identifies the name of the primary insurer REMARKS This field identifies information needed by the contractor to assist in additional CODE development Up to three remarks codes may be displayed ADDRESS 1 This field provides the address of the primary insurer ADDRESS 2 This field provides the address of the primary insurer CITY STATE ZIP This field identifies the City State and ZIP code of the primary insurer CODE GROUP NUM Insurer Group Number This field identifies the group number for the policyholder with the primary insurer TYPE This field identifies the ty
228. scriptions are provided in the table following Figure 23 JM MAC VA WV UAT 11003 DRG COST DISCLOSURE INQUIRY VERSION PPS HOSPITAL FROM DT THRU DT BM1 BASE OPER DRG AMT BPCI DEMO CODE 1 OPER HSP AMT BPCI DEMO CODE 2 VBP IND BPCI DEMO CODE 3 VBP ADJ BPCI DEMO CODE 4 HRR IND HAC RED IND HRR ADJ EHR RED IND UNCOMP CARE AMT PRESS PF3 FOR DRG PPS INQUIRY PF7 FOR PREV PAGE Figure 23 DRG Cost Disclosure Inquiry Field Name Description PVDR Displays the provider number VERSION This field identifies the program version number for the Pricer program used D DT The date for which the DRG information is being selected MMDDYY Format FROM DT The beginning date of service MMDDYY Format THRU DT The ending date of service MMDDYY Format BM1 This field identifies the Bundle Model 1 Discount Percentage This is a two position alphanumeric field in 99 format BASE OPER DRG This field identifies the Base Operating DRG Payment Amount This is the AMT amount a hospital would normally receive for the discharge of a Medicare patient BPCI DEMO Code This field identifies the Bundled Payment for Care Improvement Indicator This is 1 a two digit field and the valid values are 61 Bundled Payments for Care Model 1 62 Bundled Payments for Care Model 2 63 Bundled Payments for Care Model 3 64 Bundled Payments for Care Model 4 OPER HSP AMT Operating HSP Amount This field iden
229. service VACCINTD Beneficiary already vaccinated RECEIVED Beneficiary already received the service DODNOELG Beneficiary not eligible due to date of death Palmetto GBA Page 134 September 2015 Section 8 Health Insurance Query HIQA Page 8 PF1 INQ SCREEN DDE User s Manual Field descriptions for Page 8 of the HIQA screen are provided in the table following Figure 73 INQUIRY REPLY PF3 CLEAR END PF8 NEXT Figure 73 CWF Part A Inquiry Reply Screen Page 8 Field Name Description Palmetto GBA September 2015 Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code PROCEDURE Technical and professional description of the HCPCS procedure DESCRIPTION HCPCS CODE Healthcare Common Procedure Coding System HCPCS code of the procedure TECH PROF _ Technical or professional indicator RISK Not Used MOST RECENT Shows the three most recent dates of service for the HCPCS Technical and DATES OF Professional codes SERVICE Page 135 Section 8 Health Insurance Query DDE User s Manual HIQA Page 9 Field descriptions for Page 9 of the HIQA screen are provided in the table following Figure 74 INQUIRY REPLY PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8
230. sis or procedure Valid values are D Diagnosis code being entered updated P Procedure code being entered updated STARTING ICD The ICD 10 code is used to identify a specific diagnosis ses or inpatient surgical 10 CODE procedure s relating to a bill which may be used to calculate payment i e DRG or to make medical determinations relating to a claim D P This field identifies whether or not this is an ICD 10 diagnosis or procedure This is a one position alphanumeric field The valid values are D Diagnosis code being entered updated P Procedure code being entered updated ICD 10 CODE The ICD 10 code is used to identify a specific diagnosis ses or inpatient surgical procedure s relating to a bill which may be used to calculate payment i e DRG or to make medical determinations relating to a claim DESCRIPTION This field displays the description for the ICD 10 code EFFECTIVE This field identifies the effective and or termination date of the program TERM DATE Palmetto GBA Page 64 September 2015 Section 5 Claim Entry DDE User s Manual SECTION 5 CLAIM ENTRY This section provides information on how to enter UB 04s into the DDE format Electronic Roster Bills Hospice Election Statements The Claims and Attachments Entry Menu Main Menu option 02 may be used for online entry of patient billing information from the UB 04 Options are available to allow entry of var
231. sponsible for the admission E CODE 68 The External Cause of Injury Code field is used for E codes should be reported in second diagnosis field Form Locator 68 HOSPICE TERM Not required ILL IND IDE Identifies the Investigational Device Exemption IDE authorization number assigned by the FDA GAF Geographic Adjustment Factors This field identifies the GAF for state carrier and locality at the claim level This is a 13 digit alphanumeric field in 999999999 99 format PRV Patient Reason for Visit This field identifies the ICD 9 CM or ICD 10 CM code describing the patient s stated reason for seeking care at the time of outpatient registration This is a seven digit alohanumeric field that displays up to three occurrences PROCEDURE 74 a Enter the full code including all required digits where applicable for the CODES AND e principal procedure first code Enter the date in MMDDYY format that the DATES 01 06 procedure was performed during the billing period within the from and through dates of services in Form Locator 6 ESRD HOURS Enter the number of hours a patient dialyzed on peritoneal dialysis ADJUSTMENT Not required for new claim entry Adjustment reason codes are applicable REASON CODE only on adjustments TOB XX7 and XX8 REJECT CODE Not required by provider For Medicare contractor use only NON PAY CODE Not required by provider For Medicare contractor use only ATT PHYS 76 This
232. ssed paid rejected denied claims The claim status information is available on line for viewing immediately after the claim is updated entered on DDE The entire claim six pages can be viewed on line through the claim inquiry function but it cannot be updated from this screen Common status and location codes S LOC see Section 1 for more information are listed in the following table Code Description P B9996 Payment Floor P B9997 Paid Processed Claim Palmetto GBA Page 41 September 2015 Section 4 Claim Inquiry DDE User s Manual lere Description P B7501 Post Pay Review P B7505 Post Pay Review H B9997 Claims Processing Rejection D B9997 Medical Review Denial T B9900 Daily Return to Provider RTP Claim Not yet accessible T B9997 RTP Claim Claim may be accessed and corrected through the Claim and Attachments Corrections Menu Main Menu Option 03 S B0100 Beginning of the FISS batch process S B6000 Claims awaiting the creation of an Additional Development Request ADR letter Do not press F9 on these claims because the FISS will generate another ADR S B6001 Claims awaiting a provider response to an ADR letter S B9000 Claims ready to go to a Common Working File CWF Host Site S B9099 Claims awaiting a response from a CWF Host Site S MOnnn Suspended claims adjustments requiring Palmetto GBA staff intervention the n denotes a variety of FI
233. st letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code Palmetto GBA Page 133 September 2015 Section 8 Health Insurance Query DDE User s Manual Field Name Description INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA Preventive Services CARDIOVASC Cardiovascular COLORECTAL Colorectal FOB TEST Fecal Occult Blood Test IPP EXAM Initial Preventive Physical Examination PCB EXAM Pelvic and Clinical Breast Examination PPV Pneumococcal Pneumonia Vaccine PROSTATE Prostate PAP TEST Pap Smear Test DIABETES Diabetes GLAU Glaucoma MAMM Mammography PAPT Pap Smear Test AAA Abdominal Aortic Aneurysm AWV Annual Wellness Visit IPP EXAM Initial Preventive Physical Examination BLANK Healthcare Common Procedure Coding System HCPCS code for the preventive service TECH DTE Next eligible technical date for the preventive service listed PROF DTE Next eligible professional date for the preventive service listed The TECH DTE and PROF DTE may show abbreviations in the MMDDYYYY field Some common abbreviations that may occur include AGENOELG Beneficiary not eligible due to age GDRNOELG Beneficiary not eligible due to gender NOPTBENT Beneficiary not entitled to Part B 00000000 Service not applicable SRVNOELG Beneficiary not eligible for the
234. structured in three distinct levels including provider type classification and area of specialization FAC ZIP This field identifies the provider or subpart nine digit ZIP code DIALYSIS TYPE Valid types of dialysis include 1 Hemodialysis 2 Continuous ambulatory peritoneal dialysis CAPD 3 Continuous cycling peritoneal dialysis CCPD 4 Peritoneal Dialysis NEW SELECTION OR CHANGE Indicates an exception to other ESRD data Valid values are Y Selection Entered on initial selection or for exceptions such as when the option year is equal to the year of the select date N Change Entered for a change in selection e g option year is one year greater than the year of select date OPTION YR Identifies the year that a beneficiary selection or change is effective A selection change becomes effective on January 1 of the year following the year the ESRD beneficiary signed the selection form CWF ICN CONTRACTOR Common Working File CWF Internal Control Number ICN FISS inserts this number on the ESRD Remarks screen to ensure the correction is being made to the appropriate ESRD Remark segment Identifies the carrier or Medicare contractor responsible for a particular ESRD Maintenance file CWF TRANS DT The date that information was transmitted to the CWF CWF MAINT DT Identifies the date that a CWF response was applied to a particular ESRD record TIMES TO CWF Number of times the r
235. t Calculates a per diem payment based on the standard payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will not calculate any cost outlier portion of the payment 07 Pay without cost Calculates the standard payment without cost portion 09 Pay transfer special DRG post acute transfers for DRGs 209 110 211 014 113 236 263 264 429 483 Calculates a per diem payment based on the standard DRG payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will calculate the cost outlier portion of the payment if the adjusted charges on the bill exceed the cost threshold 11 Pay transfer special DRG no cost post acute transfers for DRGs 209 110 211 014 113 236 263 264 429 483 Calculates a per diem payment based on the standard DRG payment if the covered days are less than the average length of stay for the DRG if covered days equal or exceed the average length of stay the standard payment is calculated It will not calculate the cost outlier portion of the payment TOTAL CHARGES The total covered charges submitted on the claim DOB The beneficiary s date of birth MMDDYYYY format OR AGE The beneficiary s age at the time of discharge This field may be used instead
236. t explanation of the reason for the void cancel in the remarks section on Page 04 of the claim 6 To back out without transmitting the void cancel press F3 Any changes made to the screens will not be updated 7 Press F9 to update enter the cancel claim into DDE for reprocessing and payment retraction Palmetto GBA Page 109 September 2015 Section 6 Claim Correction DDE User s Manual 8 Check the remittance advice to ensure the claim canceled properly VALID CLAIM CHANGE CONDITION CODES Adjustment condition code will be needed to indicate the primary reason for initiating an on line claim adjustment or void cancel Valid code values include DO Changes to service dates D1 Changes to charges Note When there are multiple changes to a claim in addition to changes to charges the D1 changes to charges code value will take precedence D2 Changes to Revenue Codes HCPCS D3 Second or subsequent interim PPS bill D4 Change in GROUPER input D5 Cancel only to correct a HICN or Provider identification number For XX8 TOB only D6 Cancel only to repay a duplicate payment or OIG overpayment includes cancellation of an outpatient bill containing services required to be included on the inpatient bill For XX8 TOB only D7 Change to make Medicare the secondary payer D8 Change to make Medicare the primary payer D9 Any other change Use this code only if no other code applies Adjusted claims submitted with this conditio
237. t lifetime reserve days the patient elected to use during this billing period LAST 8a Patient s last name FIRST 8a Patient s first name MI 8a Patient s middle initial DOB 10 The patient s date of birth in MMDDYYYY format ADDR 9a e Patient s street address Must input in fields 1 and 2 State is a 2 character 1 6 field CARR This field identifies the value codes carrier number The carrier number is the identification number of the Medicare carrier as designated by the CMS This field is a five digit alphanumeric field NOTE The carrier and locality information is associated with the nine digit service facility zip code on the claim record in an available space on MAP1711 LOC This field identifies the value codes locality code The locality code is a specific location of a provider of services in a given state falling under the realm of a particular carrier s jurisdiction It is a two digit alphanumeric field NOTE The carrier and locality information is associated with the nine digit service facility zip code on the claim record in an available space on MAP1711 ZIP 9d Patient s valid zip code minimum of 5 digits SEX 11 The patient s sex Refer to your UB 04 Manual for valid values MS The patient s marital status Not required Refer to your UB 04 Manual for valid values ADMIT DATE 12 Enter date patient was admitted HR 13 Enter the hour the patient was admitted for hospitals only TYPE 14 The type of admissio
238. t provider number associated with the claim you wish to view is not entered an error message PROCESS COMPLETE NO MORE DATA THIS TYPE will be received S LOC Status and location allows you to type a particular status and location you want to view See Section 1 for more information regarding status and location codes TOB Type of bill allows you to enter a particular type of bill you want to view The TOB field consists of 3 digits The first position indicates the type of facility The second indicates the type of care The third position indicates the bill frequency The first two positions are required for a search OPERATOR ID Operator ID is automatically displayed and indicates the individual who accessed the screen FROM DATE Type the From Date of service you want to view in MMDDYY format TO DATE Type the To Date of service you want to view in MMDDYY format DDE SORT This field allows the listed claims to be sorted according to specific criteria Note This is only accessible in Claims Correction mode MEDICAL This field is used to narrow the claim selection for inquiry This provides the ability REVIEW SELECT to view only claims pending or returned for medical review Note This field is only accessible in Claims Correction mode SEL This field is used to select a claim to view or update Tab down to the claim and enter an S to view or a U to update Note When this screen appea
239. t will be blank Palmetto GBA September 2015 Page 118 Section 7 Online Reports DDE User s Manual Field Name Description LAST TRAN Identifies the date of the most recent transaction on this claim in MMDDYY format SUB IND Identifies the mode of submission of the claim If the UBC is a 7 or 8 hard copy indicator this will be a P paper claim otherwise it will contain an A automated claim SUSP TYPE The suspense location where the claim resides within the system Valid values are MED Medical Location code positions 2 amp 3 is 50 MS Location code positions 2 amp 3 is 80 or 85 CWFR Location code positions 2 amp 3 is 90 CWF Regular Location code position 4 is not B F J L or M CWFD Location code positions 2 amp 3 is 90 CWF Delayed Location code position 4 IS B F J L or M SUSP Suspense Any suspended claim Status S that does not fall into any of the categories listed above TOTAL Reflects total charges by beneficiary line item CHARGES ADS Additional Development System identifies if the claim has been to or currently resides in ADR If Location code positions 2 amp 3 have ever equaled 60 this field will contain a Y otherwise it will be blank PAT CONTROL Unique number assigned to the beneficiary at the medical facility NBR ADS
240. tained in the relevant laws regulations and rulings Any changes or new information superseding the information in this manual are provided in the Medicare Part A and Home Health and Hospice HHH Bulletins Advisories with publication dates after August 2015 Medicare Part A and HHH Bulletins Advisories are available at www PalmettoGB A com medicare In addition Current Procedural Terminology CPT codes descriptors and other data only are copyright of the 1999 American Medical Association or such other date of publication of CPT AII Rights Reserved Applicable FARS DFARS apply Palmetto GBA Page iv September 2015 Section 1 Introduction DDE User s Manual SECTION 1 INTRODUCTION Direct Data Entry DDE Online Remote Terminal Access was designed as an integral part of the Fiscal Intermediary Standard System FISS It gives Medicare providers direct access to information on their claims The FISS is a menu driven system The menu item chosen determines the system s functional capability The Main Menu includes the following sub menus Inquiry Claim Entry and Attachment Claim Correction and Online reports A DDE Medicare provider may perform the following functions electronically Submit UB 04 claims Correct adjust and cancel claims Perform inquiries such as beneficiary eligibility claims history revenue codes diagnosis codes etc View certain online reports Provider Contact Center Numbers Please check this user s manua
241. ted risk or cost based Valid values are 1 or2 MA Plan to process bills only for directly provided services and for service from provider with whom the MA plan has effective arrangements Palmetto GBA processes all other bills C MA Plan to process all bills EFF DATE Effective Date The effective date of the MA Plan TRM DATE Termination Date The termination date of the MA Plan if applicable Palmetto GBA Page 153 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Pages 6 and 7 Field definitions and completion requirements are provided in the table following Figure 89 HIQHCRO CWF HOME HEALTH INQUIRY REPLY PAGE 06 OF 16 IP REC CN NM IT DB INT 11004 PREVENTIVE SERVICE TECH DTE PROF DTE MMDDCCYY MMDDCCYY 80061 01012005 01012005 82465 01012005 01012005 82718 01012005 01012005 84478 01012005 01012005 G0104 04022002 04022002 PREVENTIVE SERVICE TECH DTE MMDDCCYY PCB EXAM G0101 07012001 PV 90732 90669 90670 VACCINTD PROSTATE G0102 GDRNOELG PROSTATE G0103 GDRNOELG COLORECTAL PAP TEST 00091 07012005 COLORECTAL DIABETES 82947 01012005 COLORECTAL G0106 04022002 04022002 DIABETES 82950 01012005 CARDIOVASC COLORECTAL G0120 04022002 04022002 DIABETES 82951 01012005 CARDIOVASC CARDIOVASC CARDIOVASC G0105 01011998 01011998 COLORECTAL
242. the delete function on Revenue Code line 0001 and add it back to the bottom to correct the total charges and units Changing total and non covered charge amounts TAB to get to the beginning of the total charge field on a line item Press END to delete the old dollar amount It is very important not to use the spacebar to delete field information Always use END when clearing a field Type the new dollar amount without a decimal point Example for 23 50 type 2350 Press ENTER The system will align the numbers and insert the decimal point Correct the totals line if necessary To exit without transmitting any corrections press F3 to return to the selection screen Any changes made to the screen will not be updated Press F9 to update enter the claim into DDE for reprocessing and payment consideration If the claim still has errors reason codes will appear at the bottom left of the screen Continue the correction process until the system takes you back to the claim correction summary Palmetto GBA Page 105 September 2015 Section 6 Claim Correction ttr mcdia aie d a The on line system does not fully process a claim It processes through the main edits for consistency and utilization The claim goes as far as the driver for duplicate check S B2500 unless otherwise set in the System Control file The claim will continue forward when nightly production batch is run Potentially the c
243. the coinsurance amount due from the beneficiary for services paid under OPPS and the reduced amount cannot be lower than 2096 of the payment rate for the line If the provider does not elect to reduce the coinsurance amount the field will contain zeros ESRD RED PSYCH HBCF The Patient End Stage Renal Disease Reduction Psychiatric Reduction Hemophilia Blood Clotting Factor will notate one of three values ESRD reduction refers to the ESRD network reduction amount and is found on Claim Page 1 in Value Code 71 Psychiatric reduction applies to line items that have a P pricing indicator The amount represents the psychiatric coinsurance amount 37 5 of covered charges Hemophilia Blood Clotting Factor represents an additional payment to the DRG payment for hemophilia The additional payment is based on the applicable HCPC This payment add on applies to inpatient claims VALCD 05 OTHER If Value Code 05 is present on the claim this field will contain the portion of the value code 05 amount that is applicable to this line item The value code 05 amount is first applied to revenue codes 96n 97n and 98n and then applied to revenue code lines in numeric order that are subject to deductible and or coinsurance PAT This field identifies the amount of the patient s blood and cash deductibles and the coinsurance amounts MSP This field identifies the Medicare Secondary Payer deductible blood and cash and
244. the DRG was calculated on MAP1781 in Figure 18 Field Name Description GROUPER The program identification number for the Grouper program used VERSION D R G The DRG code assigned by the CMS grouper program using specific data from the claim such as length of stay covered days sex age diagnosis and procedure codes discharge data and total charges MAJOR DIAG Identifies the category in which the DRG resides Valid values are CAT 01 Diseases and Disorders of the Nervous System 02 Diseases and Disorders of the Eye 03 Diseases and Disorders of the Ear Nose Mouth and Throat 04 Diseases and Disorders of the Respiratory System 05 Diseases and Disorders of the Circulatory System 06 Diseases and Disorders of the Digestive System 07 Diseases and Disorders of the Hepatobiliary System and Pancreas 08 Diseases and Disorders of the Musculoskeletal System and Connective Tissue 09 Diseases and Disorders of the Skin Subcutaneous Tissue and Breast 10 Endocrine Nutritional and Metabolic Diseases and Disorders 11 Diseases and Disorders of the Kidney and Urinary Tract 12 Diseases and Disorders of the Male Reproductive System 13 Diseases and Disorders of the Female Reproductive System 14 Pregnancy Childbirth and the Puerperium 15 Newborns and Other Neonates with Conditions Originating in the Prenatal Period 16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders 17
245. the catastrophic trailer year A YEAR DED TBM Deductible to be Met The amount of the deductible that still has to be met CO SNF Coinsurance SNF Days Remaining The number of SNF coinsurance days remaining in the period FULL SNF Full SNF Days Remaining the number of full SNF days remaining in the period DOEBA Date of Earliest Billing Action For this spell of illness DOLBA Date of Latest Billing Action For this spell of illness DED APL Deductible Applied The amount of deductible applied for this period ESRD End Stage Renal Disease CODE 1 ESRD Code 1 The beneficiary elected ESRD method 1 which means that the beneficiary will receive all supplies and equipment for home dialysis from an ESRD facility Palmetto GBA September 2015 Page 127 Section 8 Health Insurance Query DDE User s Manual Field Name Description EFF DATE Effective Date The beneficiary s ESRD effective date if he she elected ESRD method 1 CODE 2 ESRD Code 2 The beneficiary elected ESRD method 2 which means that the beneficiary will deal directly with one supplier for home dialysis supplies and equipment EFF DATE Effective Date The beneficiary s ESRD effective date if he she elected ESRD method 2 HIQA Page 2 Field descriptions for Page 2 of the HIQA screen are provided in the table following Figure 67 HIQACOP INQUIRY REPLY IP REC HOSPICE DATE START DATE1 TERM DATE1 P
246. the provider for inpatient care outpatient service or start of care in MMDDYY format PAT CONTROL Unique number assigned to the beneficiary at the medical facility NBR MED MEDICAL The total charges of the medical suspense category Location code positions 2 amp 3 50 MSP MSP Medicare Secondary Payer identifies the category heading identifying counts by Type of Bill of adjustment records meeting the following criteria Adjustment requester ID H hospital or F Fiscal Intermediary and the adjustment reason code AU BL DB ES LI VA WC or WE Location code positions 2 amp 3 80 or 85 CWFR CWF The total charges of the CWF category Location code positions 2 amp 3 90 REGULAR Location code position 4 is not B F J L or M Scroll Right NPI The National Provider Identifier NPI number of the provider rendering services to the beneficiary PROVIDER The Provider Number of the Medicare provider rendering services to the NUMBER beneficiary FROM DATE The beginning date of service for the period included on the claim in MMDDYY format THRU DATE The ending date of service for the period included on the claim in MMDDYY format ADJ IND Indicates if this record is an adjustment record If the record is a debit or credit this field will contain an asterisk otherwise i
247. the top left corner of the screen Page Reason codes will display at the bottom left of the screen to explain why the claim was returned Up to 10 reason codes can appear on a claim Pressing F1 will access the reason code file and automatically display the narrative for the first reason code listed on the left corner of the claim screen Subsequent reason codes can be entered manually to view the narrative Press F3 to return to the claim The reason code file can be accessed from any claim screen by pressing F1 The inquiry screen can also be accessed by typing the option number in the SC field in the upper left hand corner of the screen For example enter 10 for Beneficiary information screen in the SC field and press Enter Press F3 to return to the claim CORRECTING REVENUE CODE LINES To delete an entire Revenue Code line TAB to the line and type zeros over the top of the Revenue Code to be deleted or type D in the first position Press HOME to go to the Page Number field Press ENTER The line will be deleted Next add up the individual line items and correct the total charge amount on Revenue Code line 0001 To add a Revenue Code line Tabto the line below the total line 0001 Revenue Code Type the new Revenue Code information Press HOME to go to the Page Number field Press ENTER The system will resort the Revenue Codes into numerical order Perform
248. thin the state OPT Plan Option Code Restricted A Medicare contractor to process all claims B Plan to process claims for directly provided services C Plan to process all claims Unrestricted 1 Medicare contractor to process all Part A and Part B provider claims 2 Plan to process claims for directly provided services from providers with effective arrangements ENR The enrollment date of the Plan benefits for the prior year in MMDDYY format TERM Termination date of the Plan benefits for the prior year in MMDDYY format OTHER The first two occurrence codes and dates indicating another Federal Program or ENTITLEMENTS another type of insurance that may be the primary payer Valid occurrence code OCCURRENCE values include CD DATE A Working Aged beneficiary or spouse covered by Employer Group Health Plan EGHP End Stage Renal Disease ESRD beneficiary in 30 month coordination period and covered by employer health plan Medicare has made a conditional payment pending final resolution Automobile no fault or other liability insurance involvement Workers Compensation Veteran s Administration program public health service or other federal agency program Working disabled beneficiary or spouse covered by Employer Group Health Plan nmoo UJ Q Palmetto GBA Page 21 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description
249. this amount Not displayed on new claims MSP claims cannot be submitted or corrected in DDE PAYER 2 The amount entered by the user if available or apportioned by MSPPAY as payment from the secondary Medicare Secondary Payer 2 payer The MSPPAY module based on amount in the value code for the secondary payer apportions this amount Not displayed on new claims MSP claims cannot be submitted or corrected in DDE OTAF The Obligated to Accept in Full field contains the line item apportioned amount entered by the user if available or apportioned amount calculated by the MSPPAY module of the obligated to accept as payment in full This field will be populated when value code 44 is present Not displayed on new claims MSP claims cannot be submitted or corrected in DDE DENIAL IND The Medicare Secondary Payer Denial Indicator field provides the user an opportunity to tell the MSPPAY module that an insurer primary to Medicare has denied this line item Not displayed on new claims MSP claims cannot be submitted or corrected in DDE Valid values are Blank D Denied Field Name Description Palmetto GBA Page 77 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name OCE FLAGS Description X Ref The Outpatient Code Editor flags identify eight fields that are returned by the OCE module via the APC return buffer OCE flags are Flag 1 Service Flag 2 Payment Flag 3
250. this category are not included in the total count TC category AD Adjustments Within each status location Claims in this category are also counted under the standard bill category Therefore claims in this category are not included in the total count TC TC Total Count Is the total within each status location excluding claims with a category of AD MN or MP GT Grand Total For the provider of all categories in all status locations This total will print at the beginning of the listing and associated status locations will be blank The grand total is displayed only when the total by Provider is requested CLAIM COUNT The total claim count for each specific status location TOTAL CHARGES The total dollar amount accumulated for the total number of claims identified in the claim count TOTAL PAYMENT The total dollar payment amount that has been calculated by the system This is an accumulated dollar amount for the total number of claims identified in the claim count For those claims suspended in locations prior to payment calculations the total payment will equal zeros Home Health Payment Totals Select option 67 from the Inquiry Menu to access the Home Health Payment Totals Screen This screen displays the total outlier payments as well as the total amount paid to the home health agency during the calendar year Palmetto GBA Page 58 September 2015 Section 4 Claim Inquiry DDE User s Man
251. tial hospitalization Radiology and other diagnostic services Durable Medicare Equipment including orthotics and prosthetics ESRD drugs supplies and laboratory services Inpatient Rehabilitation Facility IRF PPS claims this HCPC field contains the submitted HIPPS CMG code required for IRF PPS claims e Home Health Agency HHA claims this HCPC filed contains the submitted HIPPS code with revenue code 0023 and e Other Provider services in accordance with CMS billing guidelines MODIFS 44 A 2 digit numeric or alphanumeric modifier up to 2 occurrences RATE 44 Enter the rate for the revenue code if required TOT UNIT 46 Total Units of Service indicates the total units billed This reflects the units of service as a quantitative measure of service rendered by revenue category COV UNIT 46 Covered Units of Service indicates the total covered units This reflects the units of service as a quantitative measure of service rendered by revenue category TOT CHARGE 47 Report the total charge pertaining to the related revenue code for the current billing period as entered in the statement covers period NCOV 48 Report non covered charges for the primary payer pertaining to the related CHARGE revenue code Submission of bills by providers for all stays including those for which no payment can be made is required to enable the Medicare contractor and CMS to maintain utilization records and determine eligibility on subsequent c
252. tible pints remaining to be met in the prior year PSYCH The remaining psychiatric limit in the prior year PT Physical therapy dollars remaining in the prior year OT Occupational therapy dollars remaining in the prior year Palmetto GBA September 2015 Section 4 Claim Inquiry DDE User s Manual MAP1756 JM MAC VA WV UAT 11003 ACCEPTED DATA IND PLAN CURR PLAN CUR ID OPT ENR PRIR PLAN PRI ID OPT ENR OTHER ENTITLEMENTS OCCURRENCE CD DATE ESRD CD DATE CAT DATA PSYCH DISCHG DAYS USED BLOOD MET co FL FRM TO APP CO FRM TO APP ADJ IND CALC DED CMS DT PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 12 Beneficiary CWF Screen 7 Field Name Description DATA IND Data Indicators 10 Digit Numeric Field Valid values are Pos 1 Part B Buy In 0 Does not apply 1 State buy in involved Pos 2 Alien indicator 0 Does not apply 1 Alien non payment provision may apply Pos 3 Psych Pre 0 Does not apply Entitlement 1 Psychiatric pre entitlement reduction applied Pos 4 Reason for 0 Normal Entitlement Entitlement 1 Disability DIB 2 End Stage Renal Disease ESRD 3 Has or had ESRD but has current DIB 4 Old age but had or has ESRD 8 Has or had ESRD and is covered under premium Part A 9 Covered under premium Part A Pos 5 Part A Buy In 0 No Part A Buy In 1 Part A Buy In Pos 6
253. tifies if the reason code has been has been depicted as applying to the Claim or Line NARRATIVE This field displays the description for the reason code Press F8 on the Reason Codes Inquiry screen to display the ANSI Related Reason Codes Inquiry screen Figure 30 This screen provides the ANSI reason code equivalent to the FISS reason code which can also be accessed through option 68 from the Inquiry Menu screen Press F7 to return to the Reason Codes Inquiry screen Palmetto GBA September 2015 pecpun E aah E EEE E E cere DDE y Sor s Manual ANSI Related Reason Codes Inquiry Screen MAP1882 Field Descriptions are in the table following Figure 30 MAP1882 JM MAC SC HHH UAT 11001 SC ANSI RELATED REASON CODES INQUIRY MNT REASON CODE PIMR ACTIVITY CODE DENIAL CODE MR INDICATOR PCA INDICATOR LMRP NCD ID ANSI CODES ADJ REASONS GROUPS REMARKS APPEALS A APPEALS B CATEGORY EMC HC STATUS EMC HC PRESS PF3 EXIT PF7 PREV PAGE Figure 30 ANSI Related Reason Codes Inquiry Screen Field Name Description REASON CODE This field will display the reason code entered on MAP1881 described in Figure 29 MNT Identifies the last date the reason code was updated PIMR ACTIVITY Program Integrity Management Reporting PIMR Activity Code This field CODE identifies the PIMR activity code for which the reason code is being categorized This is a two position alphanumeric field and is protected The
254. tifies the Operating HSP Hospital Specific Payment DRG amount Palmetto GBA Page 40 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description BPCI DEMO This field identifies the Bundled Payment for Care Improvement Indicator 2 This CODE 2 is a two digit field and the valid values are 61 Bundled Payments for Care Model 1 62 Bundled Payments for Care Model 2 63 Bundled Payments for Care Model 3 64 Bundled Payments for Care Model 4 VBP IND This field identifies the Value Based Pricing Indicator This is a one position alphanumeric field and the valid values are Y or N BPCI DEMO This field identifies the Bundled Payment for Care Improvement Indicator 3 This CODE 3 is a two digit field and the valid values are 61 Bundled Payments for Care Model 1 62 Bundled Payments for Care Model 2 63 Bundled Payments for Care Model 3 64 Bundled Payments for Care Model 4 VBP ADJ This field identifies the Value Based Pricing Adjustment BPCI DEMO 4 This field identifies the Bundled Payment for Care Improvement Indicator 4 This is a two digit field and the valid values are 61 Bundled Payments for Care Model 1 62 Bundled Payments for Care Model 2 63 Bundled Payments for Care Model 3 64 Bundled Payments for Care Model 4 HRR IND This field identifies the Hospital Readmission Reduction HRR Program Indicator
255. to GBA Page 156 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HIQH Pages 9 and 10 Field definitions and completion requirements are provided in the table following Figure 92 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 91 CWF Part A Inquiry Reply Screen Page 9 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT gt 0 141 Figure 92 CWF Part A Inquiry Reply Screen Page 10 CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code Palmetto GBA Page 157 September 2015 Section 9 Health Insurance Query for HHAs DDE User s Manual HOSPICE DATA Indicates if the beneficiary elected the Medicare hospice benefit START DATE1 The elected start date of a beneficiary s period of hospice coverage TERM DATE 1 Indicates the termination of the first hospice benefit period May be listed as the end of the benefits for the hospice period indicated or the revocation of hospice benefits PROV1 First Provider first provider the beneficiary has elected for hospice benefits This is the assigned Medicare provider number INTER1 First Intermediary Number Indicator as to the Medicare contractor that is processing the
256. tor Contractor 11100 12 Blue Cross Blue Shield Voluntary Agreements Contractor 11112 13 Office of Personnel Management OPM Data Match Contractor 11113 14 Workers Compensation WC Data Match Contractor 11114 Palmetto GBA September 2015 Page 44 Section 4 Claim Inquiry DDE User s Manual Field Name Description DAYS Not available in inquiry mode Revenue Codes Select option 13 from the Inquiry Menu to access the Revenue Code Table Inquiry screen This screen provides information regarding revenue codes that are billable for certain types of bills with the Fiscal Medicare contractor s system This should be referenced when you need to determine The type of revenue codes that are allowed with certain types of bills fa HCPCS code is required Jfa unitis required Jfa rate is required To start the inquiry type in the revenue code four digits ex 0550 about which you are inquiring and press ENTER Revenue Code Table Inquiry Screen MAP1761 Field descriptions are provided in the table following Figure 25 MAP1761 JM MAC SC HHH UAT 11001 REVENUE CODE TABLE INQUIRY TERM DT ALLOW HCPC UNITS RATE EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 25 Revenue Code Table Inquiry Screen Field Name Description REV CD Type the revenue code 0001 9999 that identifies a specific accommodation
257. ual Home Health Payment Totals Inquiry Screen MAP1B41 Field descriptions are provided in the table following Figure 33 JM MAC SC HHH UAT 11001 HOME HEALTH PAYMENT TOTALS INQUIRY PROVIDER NPI SEL YEAR OUTLIER TOTAL PAYMENT TOTAL PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 33 Home Health Payment Totals Inquiry Screen Field Name Description PROVIDER This field identifies the provider number NPI This field identifies the provider s National Provider Identifier NPI number SEL This field identifies the detail records for the selected Total Record and will display on the second Nap The valid value is S Select YEAR This field identifies claim information for that year by entering an S by that ear in CCYY format OUTLIER TOTAL This field identifies the Outlier total PAYMENT TOTAL This field identifies the total amount of payment ANSI Reason Code Inquiry Select option 68 from the Inquiry Menu to access the ANSI American National Standard Institute Reason Codes Inquiry Selection Screen This screen displays the remark codes that appear on both the standard paper remittance advice and the electronic remittance advice These codes signify the presence of service specific Medicare remarks and informational messages that cannot be expressed with a reason code To start the inquiry process enter the option for which you wish to obtain information e g C for claim adjustment reason
258. umber The provider s Medicare contractor e g Palmetto GBA REC HCPCS Record HCPCS Identifies the HCPCS filed FROM DT From Date The home health certification from date Palmetto GBA Page 138 September 2015 Section 8 Health Insurance Query DDE User s Manual HIQA Page 12 Field descriptions for Page 12 of the HIQA screen are provided in the PF1 INQ SCREEN table following Figure 77 INQUIRY REPLY PF3 CLEAR END PF7 PREV PF8 NEXT Figure 77 CWF PartA Inquiry Reply Screen Page 12 Field Name Description Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname last name IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth MMDDCCYY SX Sex Beneficiary s sex code INT Medicare Contractor Number The provider s Medicare contractor e g Palmetto GBA TELEHEALTH Telehealth services rendered under hospital care SERVICES HOSPITAL CARE TELEHEALTH Telehealth services rendered under nursing care SERVICES NURSING CARE HCPCS The HCPCS codes billed NEXT The beneficiary s next eligible date for services ELIGIBILE DATE RULE The Allowed HCPCS with modifier and how often Palmetto GBA September 2015 Page 139 Section 8 Health Insurance Query DDE User s Manual HIQA Page 13 Field descriptions for Page 13 of the HI
259. ure 56 R1 Summary of Reports Online Reports Selection Field Name Description REPORT NO This field identifies the number of the report Type in the desired report to view on line SEL The Selection field is used to select the report to be viewed Type an S before the desired report REPORT NO Indicates the report number FREQUENCY Reflects the frequency of the report Daily Weekly or Monthly DESCRIPTION Identifies the name or title of the report Palmetto GBA Page 112 September 2015 Section 7 Online Reports DDE User s Manual Report View Inquiry Screen R2 Scroll Layout MAP1661 Field descriptions are provided in the table following Figure 57 JM MAC SC HHH UAT 11001 REPORT VIEW INQUIRY REPORT FREQUENCY SCROLL PAGE SEARCH PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 57 R2 View A Report Field Name Description REPORT This field identifies the number of the report Type in the desired report to view on line FREQUENCY Reflects how often the report is generated Valid values are D Daily W Weekly M Monthly SCROLL This field is used to scroll to the left or right sides of the report KEY This field reflects the key or sort field for the selected report PAGE This field identifies the page number of the report being viewed SEARCH This field searches for a specific field name or value Palmetto GBA Page 1
260. ustments or XXI Medicare contractor Adjustments A cancel bill must be made to the original paid claim Providers may not reverse a cancel Canceling a claim in error will cause payment to be taken back by the Medicare contractor Providers cannot cancel an MSP claim Provider must submit an adjustment even if the claims are being changed into a no pay claim Providers may should add remarks on Claim Page 04 to document the reason for the cancel After the cancel has been stored the claim will appear in Status Location S B9000 Cancels do not appear on provider weekly monitoring reports therefore use the Claim Summary Inquiry to follow the status location of a cancel To access the claim and cancel it 1 Select the option on the Claim and Attachments Correction Menu for the type of claim to be canceled and press ENTER End Stage Renal Disease ESRD Comprehensive Outpatient Rehab Facilities CORF and Outpatient Rehab Facilities ORF will need to select the outpatient option and then change the TOB 2 Enter the HIC number and the FROM and TO dates of service and then press ENTER 3 Select the claim to be canceled by typing an S in the SEL field beside the first line of the claim and then press ENTER The HIC number field is now protected and may no longer be changed 4 Indicate why you are voiding canceling the claim by entering the claim change condition on Page 01 of the claim 5 Give a shor
261. valid values are Al Automated CCI Edit AL Automated Locally Developed Edit AN Automated National Edit CP Prepay Complex Probe Review DB TPL or Demand Bill Claim Review MR Manual Routine Review PS Prepay Complex Provider Specific Review RO Reopening SS Prepay Complex Service Specific Review Palmetto GBA Page 54 September 2015 Section 4 Claim Inquiry DDE User s Manual Field Name Description DENIAL CODE Denial Reason Code This field identifies the PIMR Denial reason code that is being categorized applies to all contractors This is a six position alphanumeric field and is protected The valid values are NOPIMR Default 100001 Documentation Does Not Support Service 100002 Investigation Experimental 100003 Item Services Excluded From Medicare Coverage 100004 Requested Information Not Received 100005 Services Not Billed Under The Appropriate Revenue Or Procedure Code Include Denials Due To Unbundling In This Category 100006 Services Not Documented In Record 100007 Services Not Medically Reasonable And Necessary 100008 Skilled Nursing Facility Demand Bills 100009 Daily Nursing Visits Are Not Intermittent Part Time 100010 Specific Visits Did Not Include Personal Care Service 100011 Home Health Demand Bills 100012 Ability To Leave Home Unrestricted 100013 Physician s Order Not Timely 100014 2 Service Not Ordered Not Inclu
262. vice NDC National Drug Code ESRD End Stage Renal Disease NIF Not in File m mI UU I MINUTES NPI National Provider Identifier FDA Food and Drug Administration FI Fiscal Intermediary FISS Fiscal Intermediary Standard System FQHC Federally Qualified Health Centers OCE Outpatient Code Editor OPM OMB Office of Management and Budget Office of Personnel Management OPPS Outpatient Prospective Payment System ORF Outpatient Rehabilitation Facility Palmetto GBA September 2015 HCPC Healthcare Common Procedure OSC Occurrence Span Code Code OTAF Obligated To Accept in Full HCPCS Healthcare Common Procedure OT Occupational Thera Coding System HHA _ Home Health Agency PC Professional Component HHPPS Home Health Prospective Payment PHS Public Health Service System PPS Prospective Payment System HICN Health Insurance Claim Number Appendix Acronyms DDE User s Manual Acronym Description Acronym Description PR Patient Responsibility PRO Peer Review Organization TC Technical Component PS amp R Provider Statistical and TOB Type of Bill Reimbursement Report PT Physical Therapy UB Uniform Billing UPC Universal Product Code UPIN Unique Physician Identification RA Remittance Advice Number RHC Rural Health Clinic URC Utilization Review Committee RTP Return To Provider SNF Skilled Nursing
263. visits are required for those revenue codes that require units on Revenue Code file The first line occurrence of non covered units on the revenue code line 0001 identifies the total non covered units for all lines containing a LUAC on MAP171D The second line occurrence of non covered units on the revenue code line 0001 identifies the total non covered units for all lines not containing a LUAC on MAP171D NON COV 48 Non Covered Charges identifies the total number of denied rejected non CHRG covered charges for each line item being denied The first line occurrence of non covered charges on the revenue code line 0001 identifies the total non covered charges for all lines containing a LUAC on MAP171D The second line occurrence of non covered charges on the revenue code line 0001 identifies the total non covered charges for all lines not containing a LUAC on MAP171D DENIAL REAS The denial reason for the revenue code line The denial code must be present in the system and pre defined in order to capture the correct denial reason OVER CODE The override code allows the operator to manually override the system generated ANSI codes taken from the Denial Reason Code file Valid values are Default to system generated A Override system generated ANSI Codes ST LC OVER The Status Location Override identifies the override of the reason code file status when a line item has been suspended Valid values are Process claim with no ove
264. will not process When an RTP is received the claim is given a Status Location code beginning with the letter T and routed to the Claims Summary Inquiry screen Claims requiring correction are located on the Claim Summary screen the day after claim entry It is not possible to correct a claim until it appears on the summary screen Providers are permitted to correct only those claims appearing on the summary screen with status T Claims that have been given T status have not yet been processed for payment consideration so it is important to review your claims daily and correct them in order to avoid delays in payment CLAIM SUMMARY INQUIRY Once an option is chosen from the Claim and Attachments Correction Menu the Claim Summary Inquiry screen Figure 52 will display Palmetto GBA Page 103 September 2015 Section 6 Claim Correction DDE User s Manual Claim Summary Inquiry Screen MAP1741 Field descriptions are provided in the table following Figure 52 MAP1741 JM MAC NC UAT PALMETTO GBA 11501 CLAIM SUMMARY INQUIRY NPI HIC PROVIDER S LOC TOB OPERATOR ID FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Figure 52 Claim Summary Inquiry Certain information is already completed including the prov
265. wing within the report SEARCH Allows searching for a particular type of claim or summary count information Cycles through Inpatient Outpatient Lab Other category REPORT The unique number assigned to the Summary of Pending Claims Other report CYCLE DATE Identifies the production cycle date in MMDDYY format TITLE OF This field is not labeled but the report title changes as the user cycles through the REPORT available Type of Bills e g Pending Processed or Returned It is located on the far right side of the screen PROVIDER Identifies the Medicare Provider rendering services to the beneficiary REASON CODE The reason code for a specific error reason condition existing The first position indicates the type and location of the reason code Valid values include 1 CMS Unibill 2 Reserved for future use 3 Fiscal Intermediary Standard System 4 File maintenance State site specific Post payment A X Miscellaneous errors oo Positions 2 5 indicate either a file or application error If position 2 contains an alpha character it is file related otherwise it is application related INPAT Reflects all claims adjustments with a Type of Bill 11X or 41X SNF Reflects all SNF claims adjustments with a Type of Bill 18X 21X 28X or 51X HHA Reflects all HHA claims adjustments with a Type of Bill 32X 33X or 34X OUTPAT Reflects all outpatient claims adjustments with a Type of Bill 13X 23X 43X 53X 73X or
266. y screen The CWF beneficiary inquiry area will display Figure 65 To access a beneficiary s CWF Master Record enter information into this screen HIQA Inquiry Screen Field definitions and completion requirements are provided in the table following Figure 65 CWF PART A INQUIRY Figure 65 CWF Beneficiary Inquiry Screen Palmetto GBA Page 123 September 2015 Section 8 Health Insurance Query Field Name RESPONSE CODE DDE User s Manual Description Data in this field a C for Display on CRT is automatically inserted by the system CLAIM NUMBER Enter the beneficiary s Medicare number as shown on the Medicare card in this field REQUESTOR ID SURNAME Enter the first six 6 letters of the beneficiary s last name INITIAL Enter the first initial of the beneficiary s first name DATE OF BIRTH Enter the beneficiary s date of birth in MMDDCCYY format SEX CODE Enter the beneficiary s sex Valid values are F Female M Male Identifies person submitting the inquiry or person requesting printed output Enter 1 in this field PRINTER DEST Leave this field blank system default printer This field is for the Printer device that the response will be directed to if a P or E is typed in the Response Code field INTER NO Identifies the Medicare contractor processing the claim Enter one of the following for a beneficiary in Palmetto GBA s jurisdiction 112
267. ymbol X displayed at the bottom of the screen see next term One of these clock symbols displays at the bottom of the screen when the system is X e processing your request Do not press any key until the symbol goes away and the blinking cursor returns END Press the END key to clear or delete the value in a field Do not use the spacebar to clear a field as spaces may be recognized as a character in FISS Palmetto GBA Page 1 September 2015 Section 1 Introduction DDE User s Manual Keyboard Function Keys The keyboard function keys also referred to as Program Function keys are used to initiate the functions as specified in the following table Your keyboard may identify these keys as PF1 PF2 PF3 etc or as F1 F2 F3 etc Function Key Function F1 The FISS Help Function Press F1 to obtain a description of a reason code Revenue Code Jump From claim page 2 MAP1712 press F2 to jump to MAP171D for the first Revenue Code in error Also if your cursor is placed on a F2 specific Revenue Code line on page 2 press F2 to jump to the same Revenue Code on MAP171D F3 Exiting a Claim Menu or Submenu Depending on the location of the cursor in the system press F3 to exit a claim menu or submenu and return to the previous screen Exiting the System Pressing F4 exits the entire system or terminates the session F4 After pressing F4 type CSSF LOGOFF and then press
268. ystem to generate a specific type of hard copy document HARDCPY Valid values include 2 Medical ADR 3 Non Medical ADR 4 MSP ADR 5 MSP Cost Avoidance ADR 7 ADR to Beneficiary 8 MSN Line Item or Partial Benefit Denial Letter 9 MSN Claim Level or Benefit Denial Letter MR INCLD IN The Composite Medical Review Included in the Composite Rate field that COMP identifies for ESRD bills if the claim has been denied because the service should have been included in the Comp Rate Valid value is Y the claim has been denied Note ESRD claims are no longer paid based on a composite rate CL MR IND This indicator identifies if all services on the claim received Complex Manual Medical Review The value entered in this field automatically populates the MR IND field for all revenue code lines on the claim Valid values are The services did not receive manual medical review default Y Medical records received This service received complex manual medical review N Medical records were not received This service received routine manual medical review Palmetto GBA Page 82 September 2015 Section 5 Claim Entry DDE User s Manual UB 04 Field Name X Ref Description TPE TO TPE Identifies the tape to tape flag if applicable The flag indicators across the top of the chart instruct the system to either perform or skip each of the four functions listed on the left of the chart below The first

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