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1. 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 DOB The beneficiary s date of birth in MMDDYY format SEX Valid values are F Female M Male U Unknown INTER The Intermediary 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 position alphanumeric field The valid values are Bi The provider number is a Legacy or OSCAR number NO 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 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 CWE 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 benef
2. 43 HCPC Anquity S6 667l 95 o n enr id Reader boit dor ka es eM TU ERU QUIERO URB xiu ede 44 Diagnosis amp Procedure Cade Inquipy usui eter dioi atis e ne dtr o qe Senden 46 ICD 9 CM Code Inquiry S6Ef668D resorte aeieea epia rever harto Re EE Rer erepta aereo Eg 47 Adjustment Reason Code DSQUIPU ase tptedi tati optato td naties iat EU utut os d E ELE didi 47 Adjustment Reason Codes Inquiry Selection Screen eese orae aE EEE 48 FISS Reason Codes DUE MS ae ideae Ia Nui niei ciao o epa i REI ula an ho p Mi ce tu I Maia tuse fs 49 Reason Codes Inquity Screen doe onec bmi resorte a ocv el etus aba Pe Deed bote Erebi iT 49 Palmetto GBA Pagei February 2008 Table of Contents DDE User s Manual for Medicare Part A ANSI Reason Code Moui sae case aco 51 ANSI Reason Code N ttative iecit eerte tiere eoe be i Lo tehetvcosiadansdsnteenensoe Fee EUER Co ecu 52 SECTION 5 CLAIM ENTRY 54 General TEGGLIDSEOB aod eiie ciii diui o iei MS QU UI n Rr aio au a lu ees a 54 dcum inr BEI A E EE A A E E EE 54 Electronic LIB D4 Chim Enty sosie E R dendi Ruin DE 55 UB 04 Claim Entry Pace l sia cescodectvesssissvs casseusesssoecuscnsedivascztetvacansielaasstaxttnssaspenaasttonsgaetdesasbeetisivs 55 UB 04 Clam Entry Pace 2 oett Ger E rn tH Edere v rrb estere sd rut gutreib iovis 59 UB 04 Claim Entry Page 2 Line Level Reimbursement MAP1714A
3. eene 61 UB 04 Claim Entry Page 2 MAPT71D 4 eet teret net tto treten escrives in tranne 67 UB 04 Claim Bitty Pace 9 tortie cris restreinte eie vanadate 76 UB 04 Claim Entry Page 4 ciii citis ot sinesdea tai toro Pea ib ee Perl lU ede OE 80 JB 04 Clam Entry Pages nece Pt ET RD Dt Bereit Ee 82 U B 04 Claim Entry Pace iautiee tror trem rtt ere Peor eir e tere rte eret ted 83 R ster Woe By M 85 ESRD CNIS 382 POb WBL itin e eri pine pee EAEE 87 SECTION 6 CLAIM CORRECTION 91 Online Tas C OSC se saci sie n set roren neissa aae anaE EN ENES ENOR una V C MMNe Nu IDEE eb p t ue 91 Claim Summary NGUY oriei ri E EE T E A AAR 92 Claims Correction Processimp TIPS scenens tad eE e AD EOS E E E R E EEE 93 Correcting Revenue Code Iles aded roe trei tese dtes E cons A EROE G EAREN OERI RNE DEERE 93 RIP Selection PEOCOSS oneer Ei E E EEE EEEE 94 Suppressing CO ET Cr 95 Claims Sort ODpLbOD inier d te OE Dic UU Reb eR Leda cud Xii FUEL EE I URS 96 Claus and Attachments COPFOCUODS e eoo di ini drole napa d EQ de EE EE OaE eds ipa d iaa 96 P NOMINIERT E 96 Clam Vords C ancels tacetsisercsceshcdics e beri ri esie rhe Diei tiir E E 97 Valid Claim Change Condition Codes eite tet etit het nieto ete ssie veesii ebbe e EE ise anat 98 SECTION 7 ONLINE REPORTS 99 050 Report Claims Returned to PtOVIGet iiie pp e tapa ete REMIS Ere pov IRR d Dri Pd ode HP RER SOUS 101 201 Rep
4. Status Processing Type Driver Location Location Position a Position b Positions cc Positions dd A Good M Manual 01 Status Location 00 Batch Process I Inactive O On line 02 Control 01 Common S Suspense B Batch 04 UB 04 Data 02 Adj Orbit M Manual Move P Paid Partial Pay 05 Consistency I 06 Consistency II 10 Inpatient 11 Outpatient R Reject 15 Administrative 12 Special Claims D Deny 25 Duplicate 13 Medical Review T RTP 30 Entitlement 14 Program Integrity U Ret to PRO 35 Lab HCPC 16 MSP 40 ESRD 18 Prod QC 50 Medical Policy 19 System Research 55 Utilization 21 Waiver 60 ADR 63 HHPPS Pricer 65 PPS Pricer 70 Payment 75 Post Pay 80 MSP Primary 85 MSP Secondary 90 CWF 99 Session Term AA ZZ User defined 65 Non DDE Pacemaker 66 DDE Pacemaker 67 DDE Home Health 96 Payment Floor 97 Final Online 98 Final Off line 99 Final Purged Awaiting CWF Response 22 64 User defined 68 79 User defined AA ZZ User defined Palmetto GBA February 2008 Page 3 Section 1 Introduction DDE User s Manual for Medicare Part A Document Control Number DCN The DCN number is located on the remittance advice This number must be used with adjustment cancellation bills Field Field Definition Position 1 1 Plan Code Code used to di
5. ANSI REASON CODE NARRATIVE To display the entire narrative for one specific ANSI code 1 Type an S in the S Select field to select the entire narrative for the ANSI reason code see Figure 29 Page 52 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry MAPnnnn XX HE DUGARIE A ONLINE SY si lM ANSI STANDARD CODES INQUIRY SELECTION SCREEN RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE MAO01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 rPrrrrrrrrrrrrre NARRATIVE IF YOU DISAGREE WITH WHAT WE APPROVED FOR THESE SERVICES YOU HAVE IF YOU DISAGREE WITH THIS DETERMINATION YOU HAVE A RIGHT TO APPEA IF YOU DISAGREE WITH MEDICARE APPROVED AMOUNTS AND 100 OR MORE IS SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTIFY OF OR INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL ENTRY ON INCORRECT BEGINNING AND OR ENDING DATE S ON CLAIM THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO MEDICAID FOR YOU SHOULD ALSO SEND THIS CLAIM TO THE PATIENT S OTHER INSURER WE CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED YOU THE PATIENT S PAYMENT WAS IN EXCESS OF THE AMOUNT OWED YOU MUST PAYMENT IS ON A CONDITIONAL BASIS IF NO FAULT LIABILITY WORKERS YOU HAVE NOT ESTABLISHED THAT YOU HAVE THE RIGHT UNDER THE LAW TO YOU MAY BE SUBJECT TO PENALTI
6. Palmetto GBA Page 101 February 2008 Section 7 Online Reports DDE User s Manual for Medicare Part A 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 the 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 Identifies the Health Insurance Claim Number submitted by the provider for the beneficiary listed in the name field 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 t
7. STMT DATES The statement covers from and to dates of the period covered by this bill in MMDDYY format DAYS COV Indicates the total number of covered days This field is skipped on Home Health and Hospice claims 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 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 Exclude any days classified as non covered see UB 04 X REF 8 Non covered Days and leave of absence days Exclude the day of discharge or death unless the patient is admitted and discharged the same day Do 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 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 The reason for non coverage should be explained by occurrence code
8. 4 Pull down the Terminal menu again and select Close Changing Passwords SOUTH CAROLINA amp RHHI 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 the ENTER key the system will display the message Your password has expired Please enter your new password The screen will now contain two New Password fields 2 Your cursor will be located in the first 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 TAB 3 Verify your new password by typing it identically again and press ENTER 4 The system displays the message SIGNON IS COMPLETE 5 Type FSS0 F S S zero and press ENTER The Main Menu displays Note If you receive a notice that your password has been revoked please call the Palmetto GBA EDI Technology Support Center toll free at 1 866 749 4301 If you have not used DDE for several months it may be automatically revoked NORTH CAROLINA PROVIDERS ONLY Your
9. CWE 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 ACWEF Disposition Code a 2 digit category or status of claim that indicates Page 118 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 9 Health Insurance Query for HHAs e Claim is approved e Claim is rejected e Claims will be retrieved from history Alert codes CWF requests for investigation of overlapping benefits and eligibility status Approved claims Intermediary produced provider check and remittance advice Rejected claims that require further investigation Intermediary 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 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 Iowa Oregon Minnesota Ohio North Carolina Kansas South Dakota Wisc
10. Determine DRG for Inpatient Hospital Claims Provider Contact Center Numbers Please check this user s manual 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 refer to the following phone numbers NC amp SC Part A Providers nme otn eria saccebiesadvacessexeasiviacesstscereseesedbes 1 877 567 9249 EXENIUERMCK 1 866 801 5301 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 are Cursor located on the screen T Use the keyboard arrow keys to move one character at a time in any direction within gt a field TAB Press the tab key to advance to the next field Press and hold down the SHIFT key while you press the TAB key to move back to the SHIFT TAB 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 One n or more numbers may show as variables For example 72n re
11. METHOD 382 EFFECTIVE DATE FUNCTION FN MI DOB SEX NPI FAC ZIP TAXO CD NEW SELECTION Y OR CHANGE N OPTION YR CONTRACTOR CWF MAINT DT TIMES TO CWF CWF DISP CD 382 EFFECTIVE DATE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 41 ESRD CMS 382 Inquiry Form Field Name Description OP The Operator Code identifies the last operator to update this record DT The last date that this record was processed HIC The beneficiary s Health Insurance Card number METHOD The method of home dialysis selected by the beneficiary Valid values are 1 Method I Beneficiary receives all supplies and equipment for home dialysis from an ESRD facility and the facility submits the claims for their services 2 Method II Beneficiary deals directly with one supplier and is responsible for submitting their own claim 382 EFFECTIVE DATE Identifies the date the Beneficiary s ESRD Method Selection becomes effective on the HCFA 382 form FUNCTION Three valid functions include E Entry U Update I 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 DOB Beneficiary s date of birth SEX Sex of the beneficiary Refer to your UB 04 Manual for valid values PROV Enter the ESRD Provider number or the facility for which you are entering the ESRD attach
12. 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 first screen You can also get from page to page by entering the page number in the top right hand corner of the screen Claim Page Reason codes will display at the bottom of the screen to explain why the claim was returned Up to 10 reason codes can appear on a claim e Pressing F1 will access the reason code file e Press F3 to return to the claim The reason codes can 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 instance 10 for Beneficiary information 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 Tab to the line below the total line 0001 Revenue Code Type the new Revenue Code information Press HOME to go to the
13. HHPPS 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 Page 6 Field descriptions are provided in the table following Figures 14 and 15 Palmetto GBA Page 25 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A MAPnnnn MPETDATEC ASRIE RA TOINI NERS YS TEIM XX ACCEPTED HOSPICE INFO FOR PERIODS 1 AND 2 PERIOD 1ST ST DATE PROV INTER OWNER CHANGE ST DATE PROV INTER 2ND ST DATE PROV INTER TERM DATE OWNER CHANGE ST DATE PROV INTER 1ST BILLED DT LAST BILLED DT DAYS BILLED REVO IND PERIOD 1ST ST DATE PROV INTER OWNER CHANGE ST DATE PROV INTER 2ND ST DATE PROV INTER TERM DATE OWNER CHANGE ST DATE PROV INTER 1ST BILLED DT LAST BILLED DT DAYS BILLED REVO IND PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 14 Beneficiary CWF Hospice Info for Periods 1 and 2 MAPnnnC Mee Dele CTATRIE AS On NT ESTING ES Sr Veron EIM XX ACCEPTED HOSPICE INFO FOR PERIODS 3 AND 4 PERIOD 1ST ST DATE PROV INTER OWNER CHANGE ST DATE PROV INTER 2ND ST DATE PROV INTER TERM DATE OWNER CHANGE ST DATE PROV INTER 1ST BILLED DT LAST BILLED DT DAYS BILLED REVO IND PERIOD 1ST ST DATE PROV INTER OWNER CHANGE ST DATE PROV INTER 2ND ST DATE PROV INTER TERM DATE OWNER CHANGE ST DATE PROV INTER 1ST BI
14. OTHER INS 30715 OUTLIER AMT CHY ST PAYMENT DATA COIN PROVIDER PAYMENT RECEIPT DATE CHECK EFT ISSUE DATE PRICER DATA TTL BLNDED PAYMT NET INL CROSSOVER IND PARTNER ID PAID BY PATIENT PROVIDER INTEREST PAYMENT CODE FED SPEC TECH PROV CHARGES ID CLINIC CODE lt REASON CODES PRESS PF3 EXIT PF7 PREV PAGE PF9 UPDT ENTER CONTINUE Figure 39 UB 04 Claim Entry Page 6 Field Name Description INSURER S Enter the address of the insurance company that corresponds to the line on which ADDRESS 1 Medicare payer information is reported FL58 A B C AND2 CITY 1 AND2 Enter the specific city of the insurance company ST 1 AND2 Enter the specific state of the insurance company ZIP 1 AND2 Enter the specific zip code of the insurance company Payment Data This information is available for viewing in Detail Claim Inquiry Option 12 immediately after the claim is updated entered on 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 payor 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 th
15. Post payment location Reason code narrative Clean claim indicator 9 9 9 9 9 9 Additional Development Request ADR orbit counter and frequency To start the inquiry process enter the five digit numeric reason code and press ENTER To make additional inquiries type over the reason code with next reason code and press ENTER REASON CODES INQUIRY SCREEN Field descriptions are provided in the table following the examples shown in Figures 25 and 26 MAPnnnn MEESDETERGVASDEESFASEOSNMISSTENSESESSYESSISIESM XX REASON CODES INQUIRY DT 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 CAL DY PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 25 Reason Code Inquiry Screen Example 1 Palmetto GBA Page 49 February 2008 Section 4 Claim Inquiry MAPnnnn HED GAR VA NLEG NE Sos 1 le OP MAnnnn XX REASON CODES INQUIRY DT 040503 PLAN REAS NARR EFF MSN ERE 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 CAL DY AN INPATIENT OUTPATIENT OR SNF CLAIM HAS SERVICE DATES EQUAL TO OR OVERLAPPING A HOSPICE ELECTION PERIOD THEREFORE NO MEDICARE PAYMENT CAN BE MADE IF BILLING IS FOR THE TREATMENT OF A NON TERMINAL CONDITION FOR THE HOSPICE PATIENT PLEASE RESUBMIT CLAIM WITH THE APPROPRIATE CONDITION CODE DDE User s Manual for Medicare Part A PROCESS COMPLETED NO MORE DATA THIS TYPE PRES
16. Section 7 Online Reports MAPnnnn KEY nnnnnn REPORT 201 CYCLE DATE BLUE CROSS CODE NAME BENEFICIARY A PAT CONTROL NBR BENEFICIARY B PAT CONTROL NBR BENEFICIARY C PAT CONTROL NBR BENEFICIARY D PAT CONTROL NBR CLAIMS COUNT NAME TOTAL CHARGES ADJUSTMENTS COUNT TOTAL CHARGES REPORT 201 nn nn nn FREQUENCY W PAGE 000001 MED REC NUMBER nnnnnnnnn Rnnnnnnnnnn nnnnnnnnn Rnnnnnnnnnn nnnnnnnnn Rnnnnnnnnnn DDE MED MEDICAL 0 MED REC NUMBER 0 00 0 0 00 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 51 201 Pended Processed and Returned Claims Scroll Left View SEARCH HIC NUMBER nnnnnnnnnD nnnnnnnnnA nnnnnnnnnA nnnnnnnnnA MSP MSP 0 HIC NUMBER 0 00 0 0 00 MEDICARE PART A 00 SUMMARY OF PENDED CLAIM INPATIENT RECD ADMIT DATE DATE 12 20 02 12 02 02 1 12 20 02 12 06 02 1 12 20 02 11 21 02 1 06 12 03 07 14 03 0 CWFR CWF REGULAR 51 RECD ADMIT DATE DATE 2 898 255 18 0 0 00 MAP1661 KEY nnnnnn REPORT 201 380 CYCLE DATE 10 31 0 S BLUE CROSS CODE FROM THRU NAME DATE DATE BENEFICIARY A 2 02 02 12 14 02 PAT CONTROL NBR BENEFICIARY B 2 06 02 12 11 02 PAT CONTROL NBR BENEFICIARY C 1 21 02 12 13 02 PAT CONTROL NBR BENEFICIARY D 7 14 03 07 23 03 PAT CONTROL NBR REPORT 201 FREQUENCY W PAGE 000001 CWFD ADJ IND SEARCH PAGE 1 FREQUE
17. 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 DISCHG The remaining lifetime psychiatric days IND 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 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 Through Date of the earliest processed bill IND The yearly data indicators Palmetto GBA February 2008 Page 23 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name Description Pos 1 0 Not Used 2 Cler
18. 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 deductible 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 Page 20 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Page 4 Field descriptions are provided in the table following Figure 12 MAPnnnn HEDUGCARE A NLUNE SYN SIT EIN XX ACCEPTED DATA IND 0000000000 NAME SMITH JOHN L ZIP 29440 PLAN ENR CD CURR PLAN CURR ID 00000 OPT CD 0 ENR PRIR PLAN PRI ID 00000 OPT C
19. VPA EUR ESC ODIE IS AETA MO UNIT S ETAN ST MSP APP IND 03 06 09 PLEASE ENTER DATA PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF7 PREV PF8 NEXT Figure 32 UB 04 Claim Entry Screen Page 1 Field Name M Description SV Suppress View This field allows a claim to be suppressed 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 STATUS The Status code identifies the condition and of the claim within the system LOCATION The Location code identifies where the claim resides within the system OSCAR 51 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 to 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 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 This field identifies the National Provider Identifier number TRANSFE
20. or you can just press ENTER and a list of ANSI reason codes will display Field descriptions are provided in the table following Figure 28 Palmetto GBA February 2008 Page 51 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A MAPnnnn HE DUGARIE A ONLINE SY si ll XX ANSI STANDARD CODES INQUIRY SELECTION SCREEN RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE NARRATIVE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 28 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 Valid values include A Appeals C Adjustment reason G Groups R Reference remarks S Claim Status T Claim category STANDARD CODE The standard code within the above record type for inquiry or updating If the record code is present and no standard code is shown all standard codes for the record type will display If both record and standard codes are present the standard codes are shown All ANSI codes will be displayed 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 NARRATIVE The description of the standard code This is the only field that can be updated for a standard code
21. 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 60 Review code 02 and length of stay indicates day outlier bill is thus not eligible as cost outlier 61 Lifetime reserve days are not numeric 62 Invalid number of covered days i e 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 PROC CD USED ICD 9 CM 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 ICD 9 CM diagnosis code used by the Grouper program for calculation SEC DIAG USED ICD 9 CM diagnosis code used by the Grouper program for calculation GROUPER VER The program identification number for the Grouper program used Returned From Pricer RTN CD A Return Code that identifies the status of the claim when it has returned from the Pricer program Return codes 00 49 describe 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 r
22. Recycled claims which recycle automatically back to CWF The FISS status location definitions are 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 MA Mid Atlantic SE Southeast GW Great Western GL Great Lakes Illinois Indiana Alabama Idaho North Dakota Michigan Maryland Mississippi Iowa 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 HIQA function the CWF beneficiary inquiry area will display Figure 55 To access a beneficiary s CWF Master Record enter information into this screen Field definitions and completion requirements are provided in the table following Figure 55 CWF PART A I
23. The amount represents the psychiatric coinsurance amount 37 596 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 If Value Code 05 is present on the claim this field will contain the OTHER 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 MSP BLOOD This field identifies the Medicare Secondary Payer Blood Deductible DEDUCTIBLE amount calculated within the MSPPAY module and apportioned upon return from the MSPPAY module MSP CASH This field identifies the Medicare Secondary Payer Cash Deductible DEDUCTIBLE amount calculated within the MSPPAY module and apportioned upon return from the MSPPAY module MSP This field identifies the Medicare Secondary Payer Coinsurance amount COINSURANCE calculated within the MSPPAY module and apportioned upon return from the MSPPAY module ANSI ESRD This 2 character Group Code and 3 character Reason Adjustment Code RED PSYCH is used to send ANSI information to the Financial System for reporting on HBCF the remittance advice for the ESRD Reduction Psychiatric Coinsurance Hemophilia Blood Clotting Factor ANSI VALCD This 2
24. 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 NC Providers follow instruction steps 8 12 then proceed to step 15 Figure 1 CICS SignOn Screen 8 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 9 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 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 North Carolina Providers section If you have not used DDE for several months it may be automatically revoked and please contact the Palmetto GBA EDI Technology Support Cen
25. 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 UB 04 CLAIM ENTRY PAGE 2 LINE LEVEL REIMBURSEMENT MAP171A This screen displays line item payment information and allows entry of more than two modifiers Access the MAP171A screen Figure 34 by pressing F2 or F11 on Page 2 MAP171 Field descriptions are provided in the table following Figure 34 MAPnnnA MUESDOTOGTASROESTATGOUNSESTONDESUSSYSSOISESMOOGIEATMSPAGE S02 XX CLAIM ENTRY DCN RECEIPT DATE TOB STATUS LOCATION STMT COV DT TO 1 REV HCPC MODIFIERS DATE RATE TOT UNT COV UNT TOT CHRG COV CHRG ANES CF ANES BV PC TC IND DEDUCTIBLES COINSURANCE ESRD RED VALCD 05 BLOOD CASH WAGE ADJ REDUCED PSYCH HBCF OTHER PAT MSP ANSI gt OUTLIER gt PAY HCPC PAYER 1 PAYER 2 OTAF DENIAL IND OCE FLAGS APC CD MSP 11213141516718 ID RESP PAT LABOR NON LABOR PROV MED PRICER PAY ASC ADJUSTMENT ANSI AMT RTC METHOD IDE NDC UPC GRP CONTR gt 30715 lt REASON CODES PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DN PF7 PRE PF8 NXT PE9 UPDT PF10 ET PF11 RT Figure 34 UB 04 Claim
26. s six digit Medicare provider number 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 Leave this field blank Reason Code Indicates the reason for the inquiry Valid codes are 1 Status Inquiry 2 Inquiry relating to an admission A I is automatically inserted in this field by the system HIQA PAGE 1 Field descriptions for Page 1 of the HIQA screen are provided in the table following Figure 56 HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 06 IP REC NM DOE IT J DB 01011911 SX M IN nnnnn PN nnnnnn REAS 1 DATETIME 97049 122129 REQ 1 DISP CODE 02 MSG UNCONDITIONAL ACCEPT CORRECT nnnnnnnnnA NM IT DB SX DBCEN 9 A ENT 020180 A TRM 000000 B ENT 020180 B TRM 000000 DOD 000000 LRSV 60 LPSY 190 DAYS LEFT FULL HOSP CO HOSP FULL SNF CO SNF IP DED BLOOD DOEBA DOLBA CURRENT 58 30 20 80 000 0 013195 020295 PRIOR 52 30 20 80 000 0 050691 051491 PARTB YR 97 DED TBM 10000 BLD3 YR 96 DED TBM 00000 BLD 3 DI 0000000000 FULL NAME DOE JOHN Q CURR ID 00000 OPT 0 ENR 000000 TERM 000000 PRIORID 00000 OPT 0 ENR 000000 TERM 000000 PARTA YR BLD 3 CATASTROPHICA DED TBM BLOOD CO SNF FULL SNF DOEBA DOLBA DED APL YEAR 89 0000000 02
27. 008 142 120489 120889 0056000 ESRD CODE 1 EFF DATE CODE 2 EFF DATE PFI INQ SCREEN PF3 CLEAR END PF8 NEXT Figure 56 CWF Part A Inquiry Reply Screen Page 1 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname Page 110 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 8 Health Insurance Query Access Field Name Description IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex code IN Intermediary Number The provider s intermediary PN Provider Number The agency s Medicare provider number APP Applicable Date Used for spell determination REAS Reason Code Indicates the reason for the inquiry DATETIME Date and Time Stamp Julian date REQ Requestor ID 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 Consisten
28. 1994 09 01 1992 TRM DATE 02 29 1996 02 29 1996 02 29 1996 INTER 10250 00885 00230 DOA 11 18 1995 04 02 1996 05 31 1996 PFI INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 66 CWF Part A Inquiry Reply Screen Page 4 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex Valid values are M Male F Female REC Record Number MSP This code is used to differentiate how information is located followed by an explanation for investigation Note MSP codes may not be available with all inquiries Valid values are A Claims Processing B IRS SSA CMS Data Match C First claim development D Mass Mailing E Black Lung DOL F Veterans VA G Other data matches H Workers compensation I Notified by beneficiary J Notified by provider K Notified by insurer L Notified by employer M Notified by attorney N Notified by EGHP Primary payer DESCRIPTION Name of Insurance EGHP Workers Comp etc EFF DATE Effective Date TRM DATE Termination Date INTER Intermediary Number DOA Date of Accretion date record was set up Page 124 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A DDE User s Manual for Med
29. APPROPRIATE CONDITION CODE PROCESS COMPLETED NO MORE DATA THIS TYPE PRESS PF3 EXIT PF6 SCROLL FWD PF8 NEXT Figure 45 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 instance 15 for DX PROC Codes Press F3 to return to the claim Press F3 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
30. 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 SNF FULL DAYS 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 Prior Benefit Period Data FRST BILL DT The date of the earliest billing action in the current benefit period LST BILL DT 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 The number of hospital coinsurance days the beneficiary patient has remaining in the current benefit period SNF FULL DAYS The number of SNF full days the beneficiary patient has remaining in the current benefit period SNF PART DAYS
31. Blank Reserved for future use 22 23 Site Code When Use Site Processing on the Site Control is set to Y these positions coincide with the value indicated in the Site field on the Operator Control File Page 4 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 2 Connection Instructions SECTION 2 CONNECTION INSTRUCTIONS Palmetto GBA uses AT amp T Passport software through IVANS network services to establish the connection between the provider and Palmetto GBA You must first connect to IV ANS before selecting DDE functions Palmetto GBA s Part A and RHHI contracts are divided into three claims processing regions The three regions are 1 North Carolina Region The NC Region is for NC Part A transactions only Note that RHHI for NC is included in the Southeast Region 2 Gulf Coast amp Midwest Region The Gulf Coast Midwest Regions consists of the following states for RHHI transactions Gulf Coast Midwest Alabama Illinois Florida Indiana Georgia Ohio Mississippi 3 Southeast Southwest Region including South Carolina Part A The Southeast Southwest Region consists of the following states Southeast Southwest Kentucky Arkansas North Carolina RHHI only Louisiana South Carolina both Part A amp RHHI New Mexico Tennessee Oklahoma Texas Connection Procedures 1 Ensure that your modem and telephone line are properly connected 2 Double click on t
32. Health Insurance Query Access DDE User s Manual for Medicare Part A Field Name Description 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 Intermediary that is NUMBER 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 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 Intermediary to process hospice claims for second provider NUMBER number 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 HIQA PAGE 3 Field descriptions for Page 3 of the HIQA screen are provided in the table following Figure 58 HIQA HIQACOP IP REC PAP MAMM
33. IMMUNO TRANSPLANT DATA HOSPICE DATE START DATEI TERM DATEI PROVI INTER 1 DOEBA DATE DOLBA DATE DAYS USED START DATE2 PROV2 INTER2 CN nnnnnnnnA CWF PART A INQUIRY REPLY PAGE 03 OF 06 NM DOE DB 010111 SX M PAPDATE 00000 TECH PROF COV IND IT J 1 0000 0000 TRANS IND 2 0000 0000 DISCH DATE 3 0000 0000 00000 00000 00000 OWNER CHANGE 1 000000 PERIOD 2 000000 000000 OWNER CHANGE 2 000000 000000 PERIOD 1 000000 000000 000000 000 000000 000000 000000 000 000000 000000 000000 REVOCATION IND PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 58 CWF Part A Inquiry Reply Screen Page 3 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s Date of Birth Page 114 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 8 Health Insurance Query Access Field Name Description SX Sex Beneficiary s sex Valid values are M Male F Female 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 for mammography screen
34. 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 Report title changes as the user cycles through the available Type of Bills REPORT e g Pending Processed or Returned BLUE CROSS The BCBS identification number assigned to a particular provider facility CODE TYPE OF CLAIM 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 by CMS This number is to be used on all correspondence and to facilitate the payment of claims RECD DATE The date on which the Intermediary received the claim from the provider in MMDDYY format ADMIT DATE The date the patient was admitted to the provider for inpatient care outpatient service or start of care in MMDDYY format 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 credi
35. MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 7 Inquiry Menu 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 Screens 1 amp 2 MAPI751 amp MAP1752 Patient eligibility information in the FISS Palmetto GBA Page 13 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Screens 3 amp 4 MAP1755 amp MAP1756 Patient eligibility information housed at the CWF Screen 5 MAP1757 Patient PAP Mammography and Transplant information Screen 6 MAP1758 Patient Hospice Benefit periods 1 and 2 Screen 7 MAP175C Patient Hospice Benefit periods 3 and 4 if applicable Screen 8 MAP1759 Patient Medicare Secondary Payer MSP information if applicable this page will not exist for all beneficiaries Screen 9 MAP175D MAP175E and MAP175F CWF Home Health information if applicable Screen 10 MAP175G CWF MAP Period if applicable Screen 11 MAP175H CWF HMO period if applicable Screen 12 MAP175I CWF Hospice period if applicable 9 9 9 9 9 9 9 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
36. OOS Sooo oe es eS cec ccc cocco C500 c O0 Sooo oe Soa a eee Ce eres Pe ee a ee Se Sooo Qoeoee of SoS oooocoooqoc cooocooo Sooo oeoaooor eS oooocooooco oc eo coo MAPnnnn REPORT 316 FREQUENCY W SCROLL R KEY nnnnnn PAGE 000001 SEARCH REPORT 316 380 PAGE 1 CYCLE DATE 10 31 0 LLS FREQUENCY WEEKLY REASON INPAT SRD CORF HOSPICE ANC OTH TOTAL CODE H C AUT AUTO H C AUTO H C AUTO H C AUTO H C AUTO E94G2 0 0 0 1 2 13599 15331 15431 16602 16603 30924 31023 31616 32300 32303 32402 37151 37192 39700 0 og 0 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF10 LEFT Figure 54 316 Errors on Initial Bills Scroll Right View Field Name Description oooor oo09ocjcoooooo9oo9o SSS SS _ OSS OOS SOS SS SS Ss ey fees fe ee Ce fee ey ee Le fey ea te See See S So er SS SS SS SS SS SS OS Ss SS Seo SSS 6 SSeS Saas SS Se SS a SS SS SS aaa C SS tae O Sa ea tS fea ea te SS Sa MYNMHNDH NA A A A SSS SSS Soa SS SI Sa a 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 Page 106 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 7 Online Reports Field Name SCROLL Description Indicates which side of the report you are viewing Scroll L is th
37. 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 ZDAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Figure 43 Claim Summary Inquiry Certain information is already completed including the provider 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 h
38. Return Code reflects the status of the claim when it has returned from the Grouper Program Return codes 00 49 describe how the bill was priced 00 Priced standard DRG payment Page 32 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description 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 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 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 Return codes 50 99 describe why the bill was not priced 51 No provider specific information found 52 Invalid MSA in provider file 53 Waiver State not calculated by PPS 54 DRG not 001 468 or 471 910
39. SNF Full SNF Days Remaining Number of SNF days remaining to be paid at coinsurance benefits Palmetto GBA February 2008 Page 111 Section 8 Health Insurance Query Access DDE User s Manual for Medicare Part A Field Name Description 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 spell of illness DOLBA Date of Latest Billing Action For this spell of illness 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 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 non payment provision may apply C Psychiatric Pre entitlement 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 CURR ID HMO Identification Code Valid values are H 2 amp 3 state code 4 amp 5 HMO number
40. This field is not currently in use DRG Pricer Grouper Select option 11 from the Inquiry Menu to access the DRG PPS Inquiry screen 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 Inquiry Approved length of stay Procedure code Provider number Covered days Sex Review code Number of lifetime reserve days Century indicator Total charges Discharge status Date of birth or age TAB to move between fields on the screen Only press ENTER when all fields have been completed DRG PPS INQUIRY SCREEN Field descriptions are provided in the table following Figure 17 Palmetto GBA Page 29 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A MAPnnnn XX DIAG CD PROC CD SEX C I REVIEW CODE APPROVED LOS HEDUGCARIE A ONLINE SYST em DRG PPS INQUIRY DISCHARGE STATUS DT PROV 420018 TOTAL CHARGES DOB OR AGE COV DAYS LTR DAYS PAT LIAB RETURNED FROM GROUPER D R G MAJOR DIAG CAT RTN CD PROC CD USED DIAG CD USED SEC DIAG USED GROUPER VER RETURNED FROM PRICER RTN CD WAGE INDEX OUTLIER DAYS AVG LENGTH OF STAY OUTLIER DAYS THRESHOLD O
41. 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 46 MAPnnnn PALMETTO GBA ONLINE REPORTS MENU R1 SUMMARY OF REPORTS R2 VIEW A REPORT ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 46 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 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 B9998 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 Palmetto GBA Page 99 February 2008 Section 7 Online Reports DDE Us
42. 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 First bill submitted during the benefit period BILLING LATEST BILLING The last bill submitted during the benefit period Page 122 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 9 Health Insurance Query for HHAs Field Name Description PARTB VISITS The number of visits reimbursed by Medicare Part B APPLIED HIQH PAGE 3 Field descriptions for Page 3 of the HIOH screen are provided in the table following Figure 65 HIQHCOP HOME HEALTH PPS INQUIRY REPLY PAGE 04 OF 05 HH REC CN nnnnnnnnnA NM DOE IT J DB 01011911 SX M START END INTER PROV DOEBA DOLBA PATIENT DATE DATE NUM NUM STAT IND 9 13 2003 11 11 2003 00380 nnnnnn 000000000 000000000 30 0 07 15 2003 09 12 2003 00380 nnnnnn 07 15 2003 09 12 2003 30 0 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 65 CWF Part A Inquiry Reply Screen Page 3
43. 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 Requestor ID Identifies person submitting the inquiry or person requesting printed output Enter 1 in this field Printer Dest Printer device that the response will be directed to if a P or E is typed in the Response Code field Leave this field blank system default printer Inter No Identifies the intermediary processing the claim Enter 00380 Palmetto GBA s Intermediary Number Provider No The number assigned by Medicare to the provider rendering medical service to the beneficiary Enter the facility s six digit Medicare provider number 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 If left blank the last two episode periods will display To search for a specific episode period enter the date in the MMDDYY format Reason Code Indicates the reason for the inquiry Valid codes are 1 Status Inquiry 2 Inquiry relating to an admission A I is automatically inserted in this field by the system Page 12
44. character Group Code and 3 character Reason Adjustment Code 05 OTHER is used to send ANSI information to the Financial System for reporting on the remittance advice for the Value Code 05 Other amount MSP 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 this amount MSP 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 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 Palmetto GBA February 2008 Page 63 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description 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 Valid values are z Blank D Denied OCE FLAGS The Outpatient Code Editor flags identify eight fields that are
45. 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 Field descriptions are provided in the table following Figure 37 on the next page MAPnnnn HWEDRGARE A ONLUNE SYS Wi CLAIM PAGE 04 XX CLAIM ENTRY REMARK PAGE 01 HIC TOB S LOC S PROVIDER REMARKS 47 PACEMAKER 48 AMBULANCE 40 THERAPY 41 HOME HEALTH 58 HBP CLAIMS MED B E1 ESRD ATTACH ANSI CODES GROUP ADJ REASONS APPEALS 30715 lt REASON CODES PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF7 PREV PF8 NEXT PF9 UPDT Figure 37 UB 04 Claim Entry Page 4 Page 80 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name MIA Description REMARKS 84 Maximum of 711 positions 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 to provide additional information to the Waiver Employee to assist that individual with
46. file Valid values include B Bundled Procedure R Rehab Audiology Function Test CORF Services 4 2 Space 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 Space CAT Category Code This field identifies the CMS category of the DME equipment 1 Inexpensive or routinely purchased DME 2 DME items requiring frequent maintenance and substantial servicing 3 Certain customized DME items 4 Prosthetic or orthotic devices S Capped rental DME items Oxygen and oxygen equipment Palmetto GBA Page 45 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name PCTC Description Professional Component Technical Component This field identifies the indicator that is added to the Comprehensive Outpatient Rehabilitation Facility CORF services Supplemental Fee Schedule PC TC HPSA Payment Policy O Pay the Health Professional Shortage Area HPS A bonus T Globally billed only the professional component of this service qualifies for the HPSA bonus payment The HPSA bonus cannot be paid on the technical component of globally billed services Action Return the service as un processable and instruct the prov
47. form locators 1 41 Page 02 Revenue HCPCS codes and charges corresponds to form locators 42 49 Page 03 Payer information diagnoses procedure codes corresponds to form locators 50 57 and 67 83 Page 04 Remarks and attachments corresponds to form locators 84 86 Page 05 Other payer and MSP information corresponds to form locators 58 66 Page 06 MSP information crossover and other inquiry does not corresponds to any form locator General Information The online system defaults to the 111 type of bill for inpatient claims 131 for outpatient claims and 211 for SNF claims 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 Field 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 REF 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 Ifany information is missing or entered incorrectly the DDE system will display reason codes at the bottom of the c
48. illness QUALIFYING Qualifying Stay Indicator This is a numeric field used to identify a qualifying IND A B 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 following Figure 60 HIQACOP IP REC EPISODE START 00000000 PF1 INQ SCREEN PF3 CLEAR END Figure 60 CWF Part A Inquiry Reply Screen Page 5 CWF PART A INQUIRY REPLY PAGE 05 OF 06 CN nnnnnnnnnA NM DOE IT J DB 01011911 SX M EPISODE END DOEBA DOLBA 00000000 00000000 00000000 PF8 NEXT Page 116 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Field Name Descri
49. 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 appear at the bottom of the screen PROCESS COMPLETED ENTER NEXT DATA RTP SELECTION PROCESS 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 MAP 1711 the first page of the claim Type Information Use the Function keys listed at the bottom of the screen to move through the claim 1 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 right hand corner of the screen Claim Page Reason Codes will appear at the bottom of the screen Figure 44 to explain why the claim was returned Up to ten reason codes can appear on a claim MAPnnnn MEESDESISGZASRSESEASSONNSISSESNESENESSYSSSISEUM CLAIM PAGE 01 XX CLAIM ENTRY SVE HIC nnnnnnnnnA TOB 131 S LOC S B0100 OSCAR nnnnnn UB FORM NPI TRANSFERING HOSPICE PROVIDER PROCESS NEW HIC PATIENT CNTL TAX SUB TAXO CD STMT DATES FROM
50. referral 4 Transfer from hospital 5 Transfer from SNF Transfer from another health care facility T Emergency room 8 Court law enforcement 9 Information not available A Transfer from CAH B Transfer from another Home Health Agency C Readmission to the same Home Health Agency 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 I 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 Palmetto GBA February 2008 Page 87 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field descriptions for the ESRD CMS 382 Inquiry screen are provided in the table following Figure 41 MAPnnnn XX HIC LN PROV DIALYSIS TYPE CWF ICN CWF TRANS DT REMARK NARRATIVE MEESD ei CeAW Ra Es Ams OMNIS iN EES S EIM OP ESRD CMS 382 INQUIRY DT
51. residence of the beneficiary Palmetto GBA Page 21 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name PLAN ENR CD Description 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 Intermediary to process all claims B Plan to process claims for directly provided services C Plan to process all claims Unrestricted 1 Intermediary 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 Gn MMDDYY format TERM DT The termination date of the Plan benefits in MMDDY Y format Prior Plan PRI ID Prior Health ID code assigned by CMS 1 H or 1 9 2 amp 3 State code 4 amp 5 Plan number within the state OPT Plan Option Code Restricted A Intermediary to process all claims B Plan to process claims for directly provided services C Plan to process all claims Unrestricted 1 Intermediary to process all Part A and Part B provider c
52. returned by the OCE module via the APC return buffer OCE flags are Flag 1 Service Flag 2 Payment Flag 3 Discounting Factor Flag 4 Line Item Denial or Rejection Flag5 Packing Flag 6 Payment Adjustment Flag 7 Type of Bill Inclusion Flag8 Line Item Action PAY HCPC APC CD HCPC Ambulatory Patient Classification Code Identifies the APC 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 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
53. the following sections Page 12 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry SECTION 4 CLAIM INQUIRY The Inquiry Menu Main Menu option 01 gives FISS users access to the following claims information Beneficiary Common Working File CWF Adjustment Reason Codes Eligibility this information is also available Revenue Cod s in HIQA and HIQH Reason Codes Healthcare Common Procedure Coding System HCPCS Codes Claims Count Summary Drug Related Grouper DRG American National Standards Institute ANSI Reason Codes two digit codes located on the remittance advice Check History International Classification of Diseases ICD 9 Codes Claims 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 provider number to inquire or input information TAB to the PROVIDER field and type in the appropriate provider number To access the Inquiry Menu select option 01 from the Main Menu The Inquiry Menu will display Figure 7 Information on each of the Inquiry Menu options follows MAPnnnn PALMETTO GBA INQUIRY MENU BENEFICIARY CWF 10 HCPC CODES 14 DRG PRICER GROUPER ilil DX PROC CODES ks CLAIMS 12 ADJUSTMENT REASON CODES 16 REVENUE CODES 13 REASON CODES ue CLAIM COUNT SUMMARY 56 ANSI REASON CODES CHECK HISTORY ET ZIP CODE FILE ENTER
54. 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 T is displayed in the OCE FLAG 1 field If the IRF PPS pricer does not change the HIPPS CMG code these fields are blank MSP Payer 1 ID This Medicare Secondary Payer Payer 1 ID code identifies the specific payer If Medicare is primary this field will be blank Valid values are 1 Medicaid 2 Blue Cross 3 Other 4 None A Working Aged Page 64 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name Description B End Stage Renal Disease ESRD Beneficiary in 12 month coordination period with an employer group health plan C Conditional Payment D Auto No Fault E Workers Compensation F Public Health Service or other Federal Agency G Disabled H Black Lung I Veterans Administration L Liability MSP Payer 2 ID This Medicare Secondary Payer Payer 2 ID code identifies the specific payer If Medicare is secondary this field will be blank Valid values are the same as for the MSP Pay
55. the Regional Office for questionable revocation Valid values are Not referred Y Referred MED REV RSNS The Medical Review Reasons field identifies a specific error condition relative to medical review There are up to nine medical review reasons that can be captured per claim This field displays medical 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 RSNS The OCE Medical Review field displays the edit returned from the OPPS 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 Identifies the Reven
56. to your UB 04 Manual for valid values FAC ZIP This field identifies the provider or subpart nine digit zip code DON 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 ANS 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 Page 58 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry UB 04 CLAIM ENTRY PAGE 2 Enter the following information on page two of the UB 04 Claim Entry screen Revenue codes in ascending numeric sequence Dollar amounts without decimal points Revenue code 001 should be used in the final revenue code entry and correspond with the totals for Total Charges and Non covered Charges List revenue codes in ascending numeric sequence Type in the dollar amounts without a decimal point e g for 45 50 type 4550 Revenue code 001 should always be the final revenue code entry and correspond with the totals for Total Charges and Non covered Charges To delete a revenue code line type 4
57. 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 Page 74 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description NON COV UNT Non Covered Units identifies the number of days visits that are being denied Denied days 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 MAPI71D 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 CHRG Non Covered Charges identifies the total number of denied rejected non 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 MAPI71D The second line occurrence of non covered charges on the revenue code line 0001 identifies the tota
58. within the state OPT HMO Option Code Describes the beneficiary s relationship with the HMO Valid values are 2 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 HMO Enrollment Date TERM HMO HMO Termination Date PER HMO Period of Enrollment Code which indicates that the individual has had 1 2 or 3 periods of enrollment in an HMO PRIOR HMO Information pertaining to Inpatient HIQA PAGE 2 Field descriptions for Page 2 of the HIQA screen are provided in the table following Figure 57 Page 112 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 8 Health Insurance Query Access HIQA HIQACOP CWF PART A INQUIRY REPLY PAGE 02 OF 06 IP REC CN nnnnnnnnnA NM DOE IT J DB 010111 SX M PAP PAPDATE 00000 MAMM TECH PROF 1 0000 0000 2 0000 0000 3 0000 0000 IMMUNO TRANSPLANT DATA COV IND TRANS IND DISCH DATE 00000 00000 00000 HOSPICE DATE PERIOD 4 OWNER CHANGE 4 PERIOD 3 OWNER CHANGE 3 START DATE1 000000 000000 000000 000000 TERM DATEI 000000 000000 PROVI INTER 1 DOEBA DATE 000000 000000 DOLBA DATE 000000 000000 DAYS USED 000 000 START DATE2 000000 000000 000000 000000 PROV2 INTER2 REVOCATION IND PFI INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 57 CWF Part A Inquiry Reply Screen P
59. zeros over the revenue code and press Enter or type D in first position of field To insert a revenue code line type it at the bottom of the list and press Enter DDE will automatically re sort the lines F2 a jump key when placed on a revenue code on MAP171A allows you to scroll to the same revenue code line on MAP171A There are additional revenue screens available Press F6 to page forward and F5 to page back To delete a revenue code line type four zeros over the revenue code and press ENTER To insert a revenue code line type it at the bottom of the list and press ENTER The system will re sort the lines See Figure 33 and the table describing the fields on the next page MAPnnnn MESESDESTECUTASBDEESCASSOSNDISTANSESSSOYESSTEESMESNICIEATMSDAGES02 XX CLAIM ENTRY REV CD PAGE 01 HIC nnnnnnnnnA TOB 111 S LOC S B0100 PROVIDER nnnnnn TOT cov CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE SERV DT PROCESS COMPLETED PLEASE CONTINUE PRESS PF2 171D PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF9 UPDT PF11 RIGHT Figure 33 UB 04 Claim Entry Revenue Screen Palmetto GBA Page 59 February 2008 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name CL UB 04 X Ref Description 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 claim The system will input the revenue cod
60. 0 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 9 Health Insurance Query for HHAs HIQH PAGE 1 Field descriptions for Page 1 of the HIOH screen are provided in the table following Figure 63 HIQHCRO IP REC PN nnnnnn DISP CODE 02 CORRECT nnnnnnnnnA NM IT DB SX A ENT 020180 A TRM 000000 CN nnnnnnnnnA APP REAS 1 CWF HOME HEALTH INQUIRY REPLY PAGE 01 OF 07 IN nnnnn REQ 1 NM DOE IT J DB 01011911 DATETIME 97049 122129 MSG UNCONDITIONAL ACCEPT SX M DBCEN 9 B ENT 020180 B TRM 000000 DOD 000000 PARTB YR 03 DED TBM 00000 FULL NAME DOE JOHN Q PFI INQ SCREEN PF3 CLEAR END Figure 63 CWF Part A Inquiry Reply Screen Page 1 PF8 NEXT Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex code IN Intermediary Number The provider s intermediary PN Provider Number The agency s Medicare provider number APP Applicable Date Used for spell determination REAS Reason Code Indicates the reason for the inquiry DATETIME Date and Time Stamp Julian date REQ Requestor ID Disposition Indicates a condition on a CABLE response Valid values are Code 01 Part A Inquiry approved 02 Par
61. 04 X Ref Description there are payer s of higher priority than Medicare enter the name of the higher priority payer on line A B Secondary Payer If Medicare is the secondary payer identify the primary payer on line A and enter Medicare on line B C Tertiary Payer If Medicare is the tertiary payer identify the primary payer on line A the secondary payer on line B and enter Medicare on line C OSCAR 51 A B Enter the Oscar Number assigned in Form Locator 50 A B C C RI 52 A B The Release of Information Certification Indicator indicates whether the C provider has on file a signed statement permitting the provider to release data to other organizations in order to adjudicate the claim AB 53 A B The Assignment of Benefits Certification Indicator shows whether the C provider has a signed form authorizing the third party payer to pay the provider PRIOR PAY 54 A B Enter the amount the provider has received from the indicated payer C toward payment on the bill prior to the Medicare billing date EST AMT DUE 55A B Not applicable C DUE FROM The Due From Patient field is for outpatient services only Enter the PATIENT amount the provider has received from the patient toward payment MEDICAL 23 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 Medic
62. 042502 TO 043002 DAYS COV 005 N C CO LTR LAST SMITH FIRST JOHN MI DOB 03031940 ADDR 1 1000 LOCUS ST 2 NEWTOWN SC 3 4 5 6 ZIP 290000000 SEX M MS M ADMIT DATE 042502 HR 00 TYPE 3 SRC 1 D HM 00 STAT 01 COND CODES 01 02 03 04 05 06 07 08 OCC CDS DATE 01 02 06 07 09 SPAN CODES DATES 01 05 09 FAC ZIP VALUE CODES AMOUNTS ANSTI_ MSP APP IND 01 01 525 00 02 Al 1000 00 PR 1 03 A3 14800 03 52505008 C087189805 06 08 09 REASON CODES PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF8 NEXT PF9Q UPDT Figure 44 UB 04 Claim Entry Page One Page 94 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 6 Claim Correction Press F1 to access the Reason Code file Figure 45 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 MAPnnnn NEES DEI CRASS ES As OnN tet NGES TOMY SITEM XX REASON CODES INQUIRY DIE PLAN REAS NARR EFF MSN ERE 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 CAL DY AN INPATIENT OUTPATIENT OR SNF CLAIM HAS SERVICE DATES EQUAL TO OR OVERLAPPING A HOSPICE ELECTION PERIOD THEREFORE NO MEDICARE PAYMENT CAN BE MADE IF BILLING IS FOR THE TREATMENT OF A NON TERMINAL CONDITION FOR THE HOSPICE PATIENT PLEASE RESUBMIT CLAIM WITH THE
63. 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 MAPI7ID 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 36 Payer Information Diagnoses Codes Attending Physician UPIN first and last name Field descriptions for Page 3 of the UB 04 Claim Entry screen are provided in the table following Figure 36 Page 76 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry MAPnnnn XX HIC nnnnnnnnnA TOB CD ID PAYER UE FROM PATIENT MEDICAL RECORD NBR DIAGNOSIS CODES 1 6 ADMITTING DIAGNOSIS IDE PROCEDURE CODES AND DATES 3 4 ESRD HOURS ATT PHYS OPR PHYS OTH PHYS 30715 ADJUSTMENT NPI NPI NPI MERIDIE AME EPA ONLUNE SVs CLAIM PAGE 03 CLAIM ENTRY S LOC S OFFSITE ZIPCD OSCAR nnnnnn PROVIDER nnnnnn RI AB PRIOR PAY EST AMT DUE COST RPT DAYS 4 5 9 END OF POA IND HOSPICE TERM ILL IND NON COST RPT DAYS 3 8 1 5 REASON CODE REJEC
64. C Utilization Review Committee V W X Y Y2K_ Year 2000 Z Palmetto GBA February 2008 Page 127
65. CENTERS for MEDICARE amp MEDICAID SERVICES Direct Data Entry DDE User s Manual for Medicare Part A CPT codes descriptors and other data only are copyright 1999 American Medical Association or such other date of publication Pa metto G BA of CPT All Rights Reserved Applicable FARS DFARS apply PARTNERS IN EXCELLENCE A CMS Contracted Intermediary and Carrier February 2008 DDE User s Manual for Medicare Part A Table of Contents TABLE OF CONTENTS SECTION 1 INTRODUCTION 1 Provider Contact Center ai GIS iuis ieitoteb a titii en M ritate dbo leta TESE ESEE icit iu dis 1 DA per c E 1 heces M porre d on NRI E RE E 2 TASS NTA Edo i Tc 3 Document Control Number DCN eiieutive iere EV ve Pre e Eta Eri E Decet dab RET 4 SECTION 2 CONNECTION INSTRUCTIONS 5 Connection Procedures ieee acc scusvetcaagaszacesnaseacuneeastelteaze cenanoedy EEIE ENESES E SENEE ASOS 5 North Carolina Sigm Onississatvnminvnnaniatiariiesiadassiii amb A A OAE 6 Gul Coast Midwest S19n Onl iore iiit reti e rcr A eden nnaads 8 Southeast Southwest SHSM OT cs ctis eee eir erise raet ep Aae oE bn xo Sis ERRER EE ER PU E A ERE ried pu bip Resa en 8 Sion Ofi ProCedutesuiss seii reris en t rn oie Fe See iae E E VERRE RUE Eee ORE HERREN A ERR RE cd 9 North Carolina Sign Off eio aieo terrre Hn IE Eh eR EH VERRE CHEESE EXER EEEE NENEN REEL PEERS 10 Gulf Coast Midwest Stgn OFF icirie
66. CMG code required for IRF PPS claims and Other Provider services in accordance with CMS billing guidelines 999 9 9 MODIFS A 2 digit alphanumeric modifier up to 2 occurrences RATE 44 Enter the rate for the revenue code if required TOT UNT 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 UNT 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 CHARGES 47 Report the total charge pertaining to the related revenue code for the current billing period as entered in the statement covers period NCOV CHARGES 48 Report non covered charges for the primary payer pertaining to the related revenue code Submission of bills by providers for all stays including those for which no payment can be made is required to enable the Intermediary and CMS to maintain utilization records and determine eligibility on subsequent claims When non covered charges are present on the bill remarks are required in UB 04 X REF 84 Page 60 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry UB 04 Field Name X Ref Description SERV DT 45 The service date is required for every line item where a HCPCS code is
67. CTIVE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 23 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 ICD 9 CODE is used to identify a specific diagnosis es 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 and the program ending date both in TERM DATE MMDDYY 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 47 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A ADJUSTMENT REASON CODES INQUIRY SELECTION SCREEN Field descriptions are provided in the table following Figure 24 MAPnnnn MIEIDATIC ATRE TA TOINI NIERS YS TEIM OP UBNO
68. D 0 ENR OTHER ENTITLEMENTS OCCURRENCE CD DATE 0 ESRD CD DATE CAT DATA PSYCH 190 DISCHG IND 0 DAYS USED BLOOD YR 89 APP MET 00560 00 BLD 3 CO 08 FL 142 FRM IND INT ADM FRM TO APP ADJ IND CALC DED CMS DT YR 89 APP MET 00560 00 BLD 3 CO 08 FL 142 FRM IND INT ADM APP ADJ IND CALC DED PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 12 Beneficiary CWF Page 4 Field Name Description DATA IND Data Indicators 10 Digit Numeric Field Valid position 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 Entitlement 0 Does not apply 1 Psychiatric pre entitlement reduction applied Pos 4 Reason for Entitlement 0 Normal 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 Rep Payee Indicator 0 Does not apply Selected for GEP Contract 2 Has Rep Payee 3 Both Conditions Apply Pos 7 10 Not used at this time Pre filled with zeros NAME Displays last name first name and middle initial of the beneficiary patient ZIP Zip Code of the
69. Disease beneficiary in his 12 month coordination period and covered by employer health plan C Medicare has made a conditional payment pending final resolution D Automobile no fault E Workers Compensation F Public Health Service or other federal agency program G Disability H Black Lung I Veteran s Administration program L Liability INSURER TYPE This field is not currently in use PATIENT Identifies the relationship of the beneficiary patient to the insured under the RELATIONSHIP policy listed Refer to NUBC Manual REMARKS Identifies information needed by the contractor to assist in additional CODES development Up to three remarks codes may be displayed Each code is a two character alphanumeric field Each site determines the values Page 28 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description INSURER INFORMATION NAME Name of the insurance company that may be primary over Medicare GROUP NO The group number for the policyholder with this insurer name ADDRESS The street city state and zip code for the insurer NAME The name of the insurer group EMPLOYER DATA NAME Name of employer that provides may provide health coverage for the beneficiary patient EMPLOYEE ID Identification number assigned by the employer to the beneficiary patient ADDRESS The street city state and zip code of the employer EMPLOYEE INFO
70. ES IF YOU BILL THE BENEFICIARY FOR PATIENT BELONGS TO AN EMPLOYER SPONSORED PREPAID HEALTH PLAN SERV YOUR CLAIM HAS BEEN SEPARATED TO EXPEDITE HANDLING YOU WILL RECEI PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD Figure 29 ANSI Related Reason Codes Inquiry Selection Screen ANSI Reason Code List 2 Press ENTER to display the ANSI Standard Codes Inquiry screen see Figure 30 MAPnnnn XX HED GCAKRIE A ONLUNE SYS TE OP MASTER ANSI STANDARD REASON CODES INQUIRY DT 083094 RECORD TYPES ARE C ADJ REASONS G GROUPS R REMARKS A APPEALS T CLAIM CATEGORY S CLAIM STATUS RECORD TYPE DA STANDARD CODE MA07 NARRATIVE THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO MEDICAID FOR REVIEN PRESS PF3 EXIT PF7 PREV PAGE Figure 30 ANSI Standard Codes Inquiry Screen Palmetto GBA February 2008 Page 53 Section 5 Claim Entry DDE User s Manual for Medicare Part A 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 various attachments The UB 04 Claim Entry consists of six 6 separate screens pages Page 01 Patient information corresponds to
71. 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 nn7 The HIC number field is now protected and may no longer be changed 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 Page 96 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 6 Claim Correction found typing 16 in the SC field in the upper right hand corner of the screen and pressing ENTER or see below 4 Give a short explanation of the reason for the adjustment in the remarks section on Page 04 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 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 previo
72. Entry Page 2 Line Level Reimbursement Field Name ME Description Untitled This field identifies the Claim Line Number of the revenue code There are 14 revenue code lines per page with a total of 450 revenue code lines per claim In entry mode this field automatically fills when the claim is processed The line number will be present for update and inquiry 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 Palmetto GBA Page 61 February 2008 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description MODIFIERS 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 RATE 44 Identifies the per unit cost for a particular line item This is the rate that was entered on MAPI1712 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 entere
73. Field Name Description i CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex Valid values are M Male F Female 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 Inter Num Medicare Intermediary number that processed the claim PROV NUM Provider Number The provider number of the home 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 1 RAP auto cancelled 2 RAP not cancelled Palmetto GBA Page 123 February 2008 Section 9 Health Insurance Query for HHAs HIQH PAGE 4 Field descriptions for Page 4 of the HIQH screen are provided in the table following Figure 66 HIQHCOP MSP REC CN nnnnnnnnnA REC 001 002 003 MSP G G G MSP PERIODS PAGE 04 OF 07 NM DOE IT J DB 01011911 SX M DESCRIPTION DISABLED DISABLED DISABLED EFF DATE 01 01 1994 01 01
74. H screen are provided in the table following Figure 68 HIQHCOP HOSP REC CN nnnnnnnnA HOSPICE DATE START DATEI TERM DATEI PROVI INTER 1 DOEBA DATE DOLBA DATE DAYS USED START DATE2 PROV2 INTER2 CWF HOSPICE PERIODS PAGE 060F 07 NM DOE IT J DB 010111 SX M PERIOD 2 000000 000000 OWNER CHANGE 2 000000 000000 PERIOD 1 000000 OWNER CHANGE 1 000000 000000 000000 000 000000 000000 000000 000 000000 000000 000000 REVOCATION IND PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 68 CWF Part A Inquiry Reply Screen Page 6 amp 7 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s Date of Birth SX Sex Beneficiary s sex Valid values are M Male F Female 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 I
75. 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 31 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 SNE wenn 24 Hospice 28 Outpatient 22 Home Health 26 Hospice Elections 87 UB 04 CLAIM ENTRY PAGE 1 After you select an option page one of the UB 04 Claim Entry screen Figure 32 will display The screen will include the Provider Number Type of Bill and default Status Location You must enter the beneficiary information name address date of birth etc and any other information needed to process the claim Field descriptions are provided in the table following Figure 32 Palmetto GBA Page 55 February 2008 Section 5 Claim Entry DDE User s Manual for Medicare Part A MAPnnnn HEDUTGCARE A ONLUNE Svs CLAIM PAGE 01 XX CLAIM ENTRY SV HIC TOB S LOC S OSCAR UB FORM NPI TRANSFERING HOSPICE PROVIDER PROCESS NEW HIC PATIENT CNTL TAX SUB TAXO CD STMT DATES FROM TO DAYS COV N C co LAST FIRST MI DOB ADDR 1 2 3 4 5 6 ZER SEX MS ADMIT DATE HR TYPE SRC OD HM COND CODES 01 02 03 04 05 06 OCC CDS DATE 01 02 06 07 SPAN CODES DATES 01 05 09 FAC ZIP
76. LLED DT LAST BILLED DT DAYS BILLED REVO IND PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 15 Hospice Info for Periods 3 and 4 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 Page 26 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description 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 in MMDDYY format PROV The hospice s Medicare provider number INTER The hospice s Intermediary 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 Intermediary number 2ND START DATE The date the second benefit period began PROV The second hospice s Medicare provider number INTER The second hospice s Intermediary number TERM 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 ho
77. NCY WEEKLY PROVIDER NUMBER 420018 LAST SUB SUSP TOTAL TRAN IND TYPE CHARGES 12 23 02 A CWFR 75 063 12 23 02 A CWFR 14 387 12 23 02 A CWFR 236 040 07 07 03 A CWFR 34 659 SUSP CLAIMS CWF DELAYED 0 SUSPENSE 9 TOTAL 60 FROM DATE THRU ADJ LAST SUB SUSP TOTAL DATE IND TRAN IND TYPE CHARGES TOTAL CHARGES 0 00 538 596 86 2 936 852 04 ADJUSTMENTS COUNT 0 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 52 201 Pended Processed and Returned Claims Scroll Right View Field Name Description 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 COUNT NAME Palmetto GBA February 2008 Page 103 Section 7 Online Reports DDE User s Manual for Medicare Part A Field Name SCROLL Description 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 viewing within the report SEARCH Allows searching for a particular type of claim or summary count information Cycles through
78. NQUIRY RESPONSE CODE CLAIM NUMBER SURNAME INITIAL DATE OF BIRTH SEX CODE REQUESTOR ID PRINTER DEST INTER NO PROVIDER NO HOST ID APP DATE REASON CODE GL GW KS MA PA NE SE SO SW Figure 55 CWF Beneficiary Inquiry Screen Field Name Description Response Code Data in this field a C for Display on CRT is automatically inserted by the system Palmetto GBA February 2008 Page 109 Section 8 Health Insurance Query Access DDE User s Manual for Medicare Part A Field Name Description Claim Number Enter the beneficiary s Medicare number in this field 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 Requestor ID Identifies person submitting the inquiry or person requesting printed output Enter 1 in this field Printer Dest Printer device that the response will be directed to if a P or E is typed in the Response Code field Leave this field blank system default printer Inter No Identifies the intermediary processing the claim Enter 00380 Palmetto GBA s Intermediary Number Provider No The number assigned by Medicare to the provider rendering medical service to the beneficiary Enter the facility
79. NTER1 First Intermediary Number Indicator as to the Medicare Intermediary that is NUMBER 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 START DATE2 Lists second start date if a beneficiary elects to change hospices during a benefit period PROV2 Indicates the Second Intermediary to process hospice claims for second provider NUMBER number 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 Page 126 Palmetto GBA February 2008 Appendix Acronyms DDE User s Manual for Medicare Part A APPENDIX ACRONYMS Acronym Description A ADR_ Additional Development Request ADJ Adjustment ASC Ambulatory Surgical Center ANSI American National Standards Institute B C CLIA Clinical Laboratory Improvement Amendments of 1988 CMHC Community Mental Health Center CMN Certificate of Medical Necessity CMS Centers for Medicare amp Medicaid Services formerly HCFA CWF Common Working File D DON Document Control Number DDE Direct Data Entry DME Durable Medical Equipment DRG Diagnosi
80. Page 117 Section 8 Health Insurance Query Access Section 9 Health Insurance Query for HHAs DDE User s Manual for Medicare Part A 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 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 as e Entitlement data e Utilization data e Claim history Information in a timely manner vi
81. Page Number field Press ENTER The system will resort the Revenue Codes into numerical order Correct the total charge amount of Revenue Code line 0001 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 Palmetto GBA Page 93 February 2008 Section 6 Claim Correction DDE User s Manual for Medicare Part A 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 of the screen Continue the correction process until the system takes you back to the claim correction summary 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
82. R Displays the identification number of the institution that rendered services to RING HOSPICE the beneficiary patient System generated for external operators that are PROVIDER directly associated with one provider Page 56 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description PROCESS NEW HIC 60 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 or the 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 claim PATIENT CNTL The patient s unique number assigned by the provider to facilitate retrieval of individual patient records and posting of the payment FED TAX NO 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 The code set is structured into three distinct levels including provider type classification and area of specialization
83. Revenue Code on MAPI7ID F3 Exiting a Menu or Submenu Depending on the location of the cursor in the system press F3 to exit a menu submenu and return to the previous screen F4 Exiting the System Pressing F4 exits the entire system or terminates the session After pressing F4 type CSSF LOGOFF and then press ENTER to complete the exit process F5 Scrolling Backwards in a Screen Page Not all information on a page may be seen on the screen at one time To review hidden data from the same screen page press F5 to scroll backwards F6 Scrolling Forward in a Screen Page To view hidden data from the same screen 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 F9 Updating Data Due to the system s design a claim will not be accepted until either 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 Screen 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 Sc
84. S OTHER INS 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 40 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 following points Only one date of service per roster page Amaximum of ten patients per roster page may be reported on a DDE roster page Field descriptions are provided in the table following Figure 40 Palmetto GBA February 2008 Page 85 Section 5 Claim Entry DDE User s Manual for Medicare Part A MAPnnnn XX HED GCARIE A ONLUNE SYST eh VACCINE ROSTER FOR MASS IMMUNIZERS RECEIPT DATE OSCAR NPI REVENUE CODE HIC NUMBER AMDIT DATE DATE OF SERV FAC ZIP CHARGES PER BENEFICIARY TYPE OF BILL TAXO CD HCPC PATIENT INFORMATION FIRST NAME ADMIT DIAG LAST NAME ADMIT TYPE INIT BIRTH DATE SEX PAT STATUS ADMIT SRCE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 40 DDE Roster Bill Page Field Name RECEIPT DATE Description The system date that the claim was received by the Intermediary OSCAR The identification number of the institution that rende
85. S PF3 EXIT PF6 SCROLL FWD PF8 NEXT Figure 26 Reason Code Inquiry Screen Example 2 Field Name Description OP Identifies the last operator who created or revised the reason code DT Identifies the date that this code was last saved 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 MSN REAS The Medicare Summary Notice reason code is used when MSNs 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 to the hard copy claims for action on EMC claims HC PRO ST LOC Hardcopy Peer Review Organization status and location code for ha
86. S code and the Locality code then press ENTER Palmetto GBA Page 43 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A HCPC INQUIRY SCREEN Field descriptions for the HCPC Inquiry screen are provided in the table following Figure 22 MAPnnnn XX CARRIER EER Dill EBES DATE URL DIT MEESDESTSGNASDEERNPASNOSNEISEPENEESESSYESISINIESM HCPC INQUIRY IND DRUG CODE LOC HCPC PROVIDER MOD A PC BASE P T TC VAL ALLOWABLE REVENUE CODES HCPC DESCRIPTION PROCESS COMPLETED PLEASE CONTINUE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 22 HCPC Inquiry Screen Field Name Description CARRIER The Medicare Intermediary identification number The Carrier Number will be system filled LOCALITY CODE 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 will 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 Nationa
87. T CODE NONPAY CODE REASON CODES PRESS PF3 EXIT PF7 PREV PF8 NEXT PF9 UPDT Figure 36 UB 04 Claim Entry Page 3 Field Name XE Description OFF SITE This field identifies offsite Clinic Outpatient department zip codes It ZIPCD determines the claim line HPSA PSA bonus eligibility CD 50 A B Use the following list of Primary Payer Codes when submitting electronic C claims for payer identification The following codes are for Medicare requirements only Other payers require codes not reflected Valid values are 1 Medicaid 2 Blue Cross 3 Other 4 None A Working age Employer Group Health Plan EGHP B End Stage Renal Disease ESRD beneficiary in 30 month coordinated period with an Employer Group Health Plan C Conditional payment 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 I Veteran s administration L Liability Z Medicare A ID Not required PAYER 50 A B Payer Identification lines C A Primary Payer 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 Palmetto GBA February 2008 Page 77 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB
88. 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 indicator column represents a blank If this field is blank all functions are performed as indicated on this chart Function Lt Transmit to CWF Print on Remittance Advice Include on PS amp R zz zo ziz zm z o z zx ziz zi c Z lt lt lt lt lt lt 2 lt s lt lt AXzx z lt lt z lt ZZ ZZN lt lt lt lt Include on Workload Palmetto GBA February 2008 Page 69 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description USER ACT The User Action Code is used for medical review and reconsideration CODE only 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 f
89. UTLIER COST THRESHOLD INDIRECT TEACHING ADJ TOTAL BLENDED PAYMENT HOSPITAL SPECIFIC PORTION FEDERAL SPECIFIC PORTION DISP SHARE HOSPITAL AMT PASS THRU PER DISCHARGE OUTLIER PORTION DIUDIDSCERMTIE DD STANDARD DAYS USED LTR DAYS USED PROV REIMB PRICER VER PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 17 DRG PPS Inquiry Screen Field Name Description DIAG CD ICD 9 CM Diagnosis Codes Six character alphanumeric fields that identify up to nine codes for coexisting conditions on a particular claim The admitting diagnosis is not entered PROC CD ICD 9 CM Procedure Codes Required for inpatient claims Seven digit field identifying the principle procedure first and up to five additional procedures 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 21800 1899 9 1900 1999 DISCHARGE The Patient s Discharge Status Code Refer to UB 04 Manual STATUS DT The date of discharge in MMDDY Y format PROV The hospital s Medicare provider number Page 30 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name REVIEW CODE Description 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 s
90. X F INTER 58300 PROV nnnnnn APP DT REASON CD 1 DATE TIME 20033021401 REQ ID BDMS DISP CD 50 TYPE 4 DATE TRANSFER INITIATED TO CMS DATE CMS INDICATED NIF AT OTHER SITE PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE Figure 10 Beneficiary CWF Page 3 Page 3 Field descriptions are provided in the table following Figure 11 MAPnnnn MEESDETSCTASDEESPASNONSNEIFETENEESSSSYAESSIEESM XX ACCEPTED CLAIM nnnnnnnnnA NAME J SMITH D O B 080219 SEX M INTER 58300 PROV nnnnnn PROV IND APP DT REASON CD 1 DATE TIME 20033030901 REQ ID BDMS DISP CD 25 I PESGESCENINDEOSB D O D A CURR ENT DT 080176 TERM DT PRI ENT DT TERM DT B CURR ENT DT 080176 TERM DT PRI ENT DT TERM DT LIFE RSRV 60 PYSCH 190 CURRENT BENEFIT PERIOD DATA FRST BILL DT 033098 LST BILL DT 040798 HSP FULL DAYS 52 HSP PART DAYS 30 SNF FULL DAYS 20 SNF PART DAYS 80 INP DED REMAIN 0 00 BLD DED PNTS 0 PRIOR BENEFIT PERIOD DATA FRST BILL DT 102997 LST BILL DT 111297 HSP FULL DAYS 55 HSP PART DAYS 30 SNF FULL DAYS 11 SNF PART DAYS 80 INP DED REMAIN 0 00 BLD DED PNTS 0 CURR B YR 03 CASH 090 00 BLOOD 3 PSYCH 02200 00 PT 01590 00 OT 01590 00 PRIR B YR 02 CASH 100 00 BLOOD 3 PSYCH 02200 00 PT 00500 00 OT 00500 00 PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 11 Beneficiary CWF Page 3 Page 18 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry
91. XX ADJUSTMENT REASON CODES INQUIRY DT 102903 SELECTION SCREEN CLAIM TYPES I INPATIENT SNF O OUTPATIENT H HOME HEALTH CORF A ALL CLAIMS PLAN CODE 1 REASON CODE S PC RC TYPE NARRATIVE 1 A AUTOMATED ADJUSTMENT I ADMISSION DENIAL TECHNICAL DENIAL PRO REVIEW CODE A I ADMISSION DENIAL NO PAYMENT MEDICAL DENIAL PRO REVIEW CODE A I ADMISSION REVERSAL HARDCOPY ADJUSTMENT A AMBULATORY SURGICAL CENTER A AUTOMOBILE I ADMISSION DENIAL PAYABLE PER WAIVER A CWF CORRUPTED BENE CORRECTION A BLACK LUNG I COST OUTLIER APPROVED A CHANGE CHARGE I COVERED DAYS CHANGES B I COST OUTLIER NO PAYMENT E I COST OUTLIER PARTIAL APPROVED A CLAIM RECONSIDERATION PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD Figure 24 Adjustment Reason Codes Inquiry Selection Screen Field Description CLAIM Describes the claim types identified for each adjustment reason code TYPES 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 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 Select
92. Y 070166 Y 070166 Y 070166 N N N N N N EA vA DEA SCA CATACAT CA 83X PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Figure 19 Revenue Code Table Inquiry Screen Field Name Description REV CD Type the revenue code 0001 9999 that identifies a specific accommodation 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 ALLOW Identifies whether the revenue code is currently valid for a specific Type of Bill Valid values are Y Yes N No HCPC Identifies whether a Healthcare Common Procedure Code HCPC is required 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 Page 40 Palmetto GBA February 2008 DDE User s M
93. a an online process Accurate initial claims processing with e Deductible access e Coinsurance access e Part A and Part B benefits paid comparison e Check editing prepayment so contractor s approval equals CMS acceptance e Duplicate payments prevention e Efficient implementation of future benefits and enhancements changes Part A CWF Send Process The Intermediary 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 intermediary paid claim to the host for approval Prior to SEND Intermediary 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
94. ace and middle initial Outpatient and Other Part B Enter the UPIN of the physician who requested the surgery therapy diagnostic tests or the physician who has ordered Home Health Hospice or a Skilled Nursing Facility admission in the first six digits followed by two spaces the physician s last name one space first name one space and middle initial Attending Physician I D All Medicare claims require UPINS e g including cases when there is a private primary insurer involved Physicians not participating in the Medicare program may obtain UPINs Additionally for outpatient and other Part B if there is more than one referring physician enter the UPIN of the physician requesting the service with the highest charge NPI This field identifies the National Provider Identifier number LN This field identifies the last name of the attending physician FN This field identifies the first name of the attending physician MI This field identifies the middle initial of the attending physician OPER PHYS 83 A B Enter the UPIN and name of the physician who performed the principal procedure Inpatient Part A Hospital Enter the UPIN and name of the physician who performed the principal procedure If no principal procedure is performed leave blank Outpatient Hospital Enter the UPIN and name of the physician who performed the principal procedure If there is no principal procedu
95. age 2 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s date of birth SX Sex Beneficiary s sex Valid values are M Male F Female 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 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 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 Palmetto GBA Page 113 February 2008 Section 8
96. anual for Medicare Part A Section 4 Claim Inquiry Field Name Description UNITS Identifies if the revenue code requires units to be present for a specific Type of Bill Valid values are Y Yes N No RATE Identifies if the revenue codes require a rate to be present for a specific Type of Bill Valid values are Y Yes N No 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 CLAIM SUMMARY TOTALS INQUIRY SCREEN 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 Field descriptions are provided in the table following Figure 20 MAPnnnn HE DU GARIE A ONLENE Ss le XX CLAIM SUMMARY TOTALS INQUIRY PROVIDER nnnnnn S LOC CAT S LOC CAT CLAIM COUNT TOTAL CHARGES TOTAL PAYMENT PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Figure 20 Claim Summary Totals Inquiry Screen Palmetto GBA Page 41 February 2008 Sec
97. are DAYS patient days for inpatient and SNF types of bills 11n 41n 18n 21n 28n and 51n on the cost report The system calculates this field and inserts the applicable data NON COST Identifies the number of Non Cost Report Days not claimable as RPT DAYS Medicare patient days for inpatient and SNF types of bills 11n 18n 21n 28n 41n and 51n on the cost report DIAGNOSIS 67 75 Used to enter the full ICD 9 CM Diagnosis Codes for the principal CODE diagnosis code and 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 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 ADMITTING 76 In the Admitting Diagnosis field for inpatients enter the full ICD 9 CM DIAGNOSIS code for the principal diagnosis relating to condition established after study to be chiefly responsible for the admission E CODE 77 The External Cause of Injury Code field is used for E codes should be reported in second diagnosis field Form Locator 68 HOSPICE N
98. ary CWF Page 5 Field 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 Page 24 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description DB The date of birth of the beneficiary patient SX Sex of the beneficiary patient Valid values Y 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 The date the technician interpreted the mammography screening PROCOM The date the mammography screening required an interpretation by a physician 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
99. ave 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 from and through dates Page 92 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 6 Claim Correction 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 If 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 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
100. becomes eligible for Medicare LAST NAME Enter the last name of the patient as it appears on the patient s Health Insurance Card or other Medicare notice Page 86 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name Description FIRST NAME Enter the first name of the patient as it appears on the patient s Health Insurance Card or other Medicare notice INIT Enter the middle initial of the patient BIRTH DATE Enter the patient s date of birth in MMDDYYYY format SEX Enter the sex of the patient Refer to your UB 04 Manual for valid values RTP This field identifies whether the claim was returned to provider The valid value is wy ADMIT DATE This field identifies the date of the patient s admission DISC DATE This field identifies when the patient was discharged ADMIT TYPE This field identifies the code indicating the priority of admission The valid values are I 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 PAT STATUS This field identifies the code indicating the patient s status at the ending service date in the period ADMIT SRCE This field identifies the way a patient was referred to the hospital for admission The valid values are I Physician referral 2 Clinical referral 3 HMO
101. c file 98 Cannot process bill older than 10 01 87 Page 66 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry UB 04 Field Name X Ref Description 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 ASC GRP Identifies the Ambulatory Surgical Center Group code for the indicated revenue code ASC 96 Identifies the Ambulatory Surgical Center Percentage used b
102. cates day outlier bill is thus not eligible as cost outlier 61 Lifetime reserve days are not numeric 62 Invalid number of covered days i e 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 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 The predetermined average length of stay for the assigned DRG OF STAY OUTLIER DAYS Shows the number of days of utilization permissible for this claim s DRG code THRESHOLD 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 THRESHOLD Payment 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 t
103. ceseees to cit ee snt orena sna eee bebes ee seu Ee Ye Ee IV EEEIEE 10 Southeast Southwest Sien OTE eanan a a semet eee inu de a nds expe ei eases 10 eripe Di mM T 10 South Carolina REHBLDPEOVIGGIS teorie br t ere beste ie v Loci E RENEE ESSENER SRE 10 North Carolina Providers Only c eitetetite t tete tts ha tra bred e ant eb irasod sta ie eb anre do 10 SECTION 3 MAIN MENU 12 SECTION d CLAIM INQUIRY 13 Benetti oy Ae EUR D Darter 13 B neticiary C WE Sereefis eios rrr re esee ee ese tai Eae HIER ub Eee lo eene esee ie EIE ERR Io dee Ee ea RF des 14 DRG Pricer Grouper T 29 DRG PPS Inquity SCt elk ete iet Hr HERR Io EUR I EE etae ie UPON aa eU Nae ete ies FRE ERRAT Pedes 29 METTI Summary TUL RTT 35 Claims Summary Inquiry Screen cease Hetero en ra oed ERR Dr aate ES ONERE Re RESET EEE Eos eed 36 Pertormiie Claus Inquiries ccce oo itte torti Riu oera tiae Hesse tese el ebore bep tee eres e tera ita eri 39 Viewing an Additional Development Request ADR Letter 39 Revenue CodeS e M S 39 Revente Code Table Inquiry S Chem 3 orto eee tt lee cuca tbe eroe eer putetis Eee eventos 40 CTI Count Summary REMO Dm 41 Claim Summary Totals Inquiry Screen ener rtt seco EE EEE ttp Eee ENEE NEEE 41 Check History rii UM 42 Check History SCLEEM edite o hie ser En nre enea Erao E SEE E Ena O E E C T iu 43 M Ed dec
104. chiatric 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 Palmetto GBA February 2008 Page 15 Section 4 Claim Inquiry Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Page 2 Field descriptions are provided in the table following Figure 9 MAPnnnn XX RI 1 SRV YR SRV YR ID CD ID CD ID CD PERIOD 2ND ST DT OWNER CHANGE ST DT 1ST BILL DT PROCESS COMPLETED MEDICAL EXPENSE BLD DED 1ST DT OWNER CHANGE ST DT HEDUGCARE A NLUNE Sst EIN ELIGIBILITY DETAIL INQUIRY PART B DATA BLD DED REM CSH DED PSY EXP PLAN DATA ERs Dill ERR DT Ene Dili OPT CD OPT CD OPT CD CANC DT CANC DT CANC DT HOSPICE DATA PROVIDER PROVIDER INTER PROVIDER LST BILL DT INTER INTER TERM DT INTER DAYS BILLED PROVIDER PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 CWF INQUIRY Figure 9 Beneficiary CWF Page 2 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 Part B Data SRV YR The calendar year f
105. claim finalization The remarks field is also used for Providers to furnish justification of late filed claims that override the Intermediary 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 Justify PRO Review involved Justify Other involvement ZIP This field identifies the zip code 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 Palmetto GBA February 2008 Page 81 Section 5 Claim Entry DDE User s Manual for Medicare Part A UB 04 CLAIM ENTRY PAGE 5 Page five of the UB 04 Claim Entry screen Figure 38 is used to enter a patient s payer information Field descriptions are provided in the table f
106. ct RD Transaction Error REMARK Valid Remark Narrative types include NARRATIVE M1 Method I M2 Method II Palmetto GBA February 2008 Page 89 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name Description 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 Page 90 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 6 Claim Correction SECTION 6 CLAIM CORRECTION The Claim and Attachments Correction Menu displays Figure 42 when 03 is chosen from the Main Menu MAPnnnn PALMETTO GBA CLAIM AND ATTACHMENTS CORRECTION MENU CLAIMS CORRECTION INPATIENT OUTPATIENT SNF HOME HEALTH HOSPICE CLAIM ADJUSTMENTS CANCELS INPATIENT OUTPATIENT SNF HOME HEALTH HOSPICE ATTACHMENTS PACEMAKER AMBULANCE THERAPY HOME HEALTH ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 42 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 t
107. ctor 11112 13 Office of Personnel Management OPM Data Match Contractor 11113 14 Workers Compensation WC Data Match Contractor 11114 DAYS Not available in inquiry mode Page 38 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry 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 e Type an S in the first position of the S LOC field to view all the suspended claims e Type a P in the first position of the S LOC field to view all the paid processed claims e Typea T in the first position of the S LOC field to view claims returned for correction From Date To Date 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 GB A s medical review department uses ADRs to request medical records from providers during the medical review process Do the following to view an ADR letter for claims in the ADR status
108. cy edit reject UR Utilization edit CR A B crossover edit CI CICS processing problem SV Security violation MSG Message The verbiage pertaining to the disposition code CORRECT Correct Claim Number Use only if HIC number is incorrect NM Corrected Name Used only if the name is not consistent with CMS s record IT Corrected Initial Used only if the initial is not consistent with CMS s record DB Corrected Date of Birth Used only if the date of birth entered is different than CMS s beneficiary record SX Corrected Sex Codes Used only if sex code is not consistent with CMS s record DBCEN Date of Birth Century Valid values are 8 1800 9 1900 A ENT Part A Entitlement Date of entitlement to Part A benefits This is ina MMDDYY format A TRM Part A Termination Indicates date of termination of Part A entitlement This is in a MMDDYY format 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 in MMDDYY format 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 FULL HOSP Full Hospital Days Remaining Indicates the inpatient days remaining to be paid at full benefits CO HOSP Co Hospital Days Remaining FULL
109. d 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 nn8 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 nn8 TOB only D7 Change to make Medicare the secondary payer D8 Change to make Medicare the primary payer D9 Any other change EO Change in patient status Page 98 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 7 Online Reports 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
110. d 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 TOT CHRG 47 The total charges displayed on this page are the same as that entered on MAPI712 COV CHRG This field identifies the covered units billed by revenue category ANES CF This field identifies the anesthesia conversion factor ANES BV This field identifies the anesthesia base values PC TC IND This field identifies the PC TC Indicator that is added to the CORF services Supplemental Fee Schedule PAT BLOOD DEDUCTIBLE The amount of Medicare Patient Blood Deductible applied to the line item Blood deductible will be applied at the line level on revenue codes 380 381 and 382 This field is system filled PAT CASH DEDUCTIBLE The amount of Medicare Patient Cash Deductible applied to the line item This field is system filled WAGE ADJ COINSURANCE The amount of Patient Wage Adjustment Coinsurance applicable to the line 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 o
111. d waiver was applied U Technical denial and waiver was not applied Palmetto GBA February 2008 Page 75 Section 5 Claim Entry DDE User s Manual for Medicare Part A UB 04 X Ref 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 Field Name Description 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 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 REMARKS 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
112. date if a beneficiary elects to change hospices during a benefit period PROV2 Indicates the Second Intermediary to process hospice claims for second provider NUMBER number 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 HIQA PAGE 4 Field descriptions for Page 4 of the HIQA screen are provided in the table following Figure 59 Palmetto GBA February 2008 Page 115 Section 8 Health Insurance Query Access DDE User s Manual for Medicare Part A HIQACOP IP REC SPELL NUM 02 01 QUALIFYING CWF PART A INQUIRY REPLY PAGE 04 OF 06 CN nnnnnnnnnA NM DOE IT J DB 01011911 SX M PARTA VISITS REMAINING EARLIEST BILLING LATEST BILLING PARTB VISITS IND APPLIED 0 0 0 0 12071999 01261998 02292000 03241999 13 59 Figure 59 CWF Part A Inquiry Reply Screen Page 4 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex Valid values are M Male F Female SPELL NUM Spell of Illness Number This number reflects the current home health spell of
113. e Assessment Completed The codes are from M0100 that is for the assessment currently being completed for the following reasons 01 Start of care further visits planned 02 State of care no further visits planned 03 Resumption of care after inpatient stay 04 Rectification follow up reassessment 05 Other follow up 06 Transferred to an inpatient facility patient not discharged from agency 07 Transferred to an inpatient facility patient discharged from agency 08 Death at home 09 Discharge from agency 10 Discharge from agency no visits completed after start resumption of care assessment Entry required if applicable UB 04 CLAIM ENTRY PAGE 6 The following information can be found on Page 6 of the UB 04 Claim Entry screen Figure 39 Medicare Secondary Payer MSP address Payment data coinsurance deductible etc Pricer data DRG etc Field descriptions are provided in the table following Figure 39 Palmetto GBA Page 83 February 2008 Section 5 Claim Entry DDE User s Manual for Medicare Part A MAPnnnn XX HIC HWEDUTGCARE A ONLUNE SYysi1e CLAIM PAGE 06 CLAIM ENTRY TOB S LOC S PROVIDER MSP ADDITIONAL INSURER INFORMATION 1ST INSURERS ADDRESS 1 1ST INSURERS ADDRESS 2 CITY ST 2ND INSURERS ADDRESS 1 2ND INSURERS ADDRESS 2 DEDUCTIBLE PAID DATE REIMB RATE CHECK EFT NO DRG GRAMM RUDMAN ORIG REIMBURSEMENT AMT TECH PROV DAYS
114. e 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 Page 84 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name Description PROVIDER Interest paid to the provider INTEREST o EFT Displays the identification number of the check or electronic funds transfers CHECK EFT Displays the date the check 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 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 The Outlier Amount qualified for outlier reimbursement AMOUNT TTL BLNDED Not utilized in DDE PAYMENT FED SPEC Not utilized in DDE GRAMM The Gramm Rudman Original Reimbursement Amount RUDMAN ORIG REIM AMT NET INL Not utilized in DDE TECHNICAL The number of days for which the provider is liable PROV DAYS TECHNICAL The dollar amount for which the provider is liable PROV CHARGE
115. e beneficiary s record contains Medicare entitlement hospice benefit information 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 as e Entitlement data e Utilization data e Claim history Information in a timely manner via an online process Accurate initial claims processing with e Deductible access e Coinsurance access e Part A and Part B benefits paid comparison e Check editing prepayment so contractor s approval equals CMS acceptance e Duplicate payments prevention e Efficient implementation of future benefits and enhancements changes Part A CWF Send Process The Intermediary 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 intermediary paid claim to the host
116. e claim number as it was originally typed 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 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 claim inquiry screen LAST NAME 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 refer to the on line reason code file Palmetto GBA February 2008 Page 37 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name Description NPC Non payment code used by the system to deny o
117. e identifying if the patient s date of birth is in the 18th or 19th century Valid values are 8 1800s 9 1900s LTR DAYS The lifetime reserve days remaining LN The patient s last name 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 MMDDY YYY format DOD The patient s date of death ADDRESS The patient s street address city and state of residence ZIP The zip code for state of residence Current Entitlement PART A EFF DT The date a beneficiary 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 benefit period LST BILL DT The ending date of 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 psy
118. e 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 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 PAGE Identifies the specific page within the report CYCLE DATE Identifies the production cycle date in MMDDYY format TITLE OF The report title changes as the user cycles through the available Type of Bills e g REPORT Pending Processed or Returned 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 5 State site specific 6 Post payment A X Miscellaneous errors 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 Bi
119. e 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 List revenue codes in an ascending sequence and do not repeat revenue codes on the same bill if possible 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 or an accommodation revenue code that requires repeating with a different rate Revenue code 001 total charges should always be the final revenue code entry 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 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 partial 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
120. e services for this hospice Provider 1 4 OWNER Displays the start date of a change of ownership within the period for the second CHANGE ST DT provider PROVIDER The Provider number of the Medicare hospice provider INTER The Intermediary number for the hospice provider 1ST BILL DT A 6 digit numeric field in MMDDY Y format that identifies the date of each earliest hospice bill 1 4 LST BILL DT A 6 digit numeric field in MMDDY Y format that identifies each most recent hospice date 1 4 DAYS BILLED A 3 digit numeric field that identifies the cumulative number of days billed to date for the beneficiary under each hospice election 1 4 Palmetto GBA February 2008 Page 17 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Page 3 NOT IN FILE NIF ERROR This response on the reply record indicates that the beneficiary record for which the Fiscal Intermediary submitted a claim is not in the CWF Region being accessed by your Intermediary Further research may be needed throughout the CWF Hosts to locate the information Sometimes because of the complexity of the CWF it may take extra time to locate the records of a beneficiary The claim will orbit until all hosts have been polled and if the information is not found successfully a CWF error message will be received Figure 10 MAPnnnA EESDETECEASDEENPAGSONNSISETENEESESSYESSIEESM XX NOT IN FILE CLAIM nnnnnnnnnA NAME J SMITH DOB 030319 SE
121. e 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 National 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 preformed For the Revenue Code Total Line 0001 the system generates a value in the first
122. e you an error message 16 The Main Menu Figure 5 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 MAP1701 PALMETTO GBA NC PART A MAIN MENU FOR REGION ACPFA321 01 INQUIRIES 02 CLAIMS ATTACHMENTS 03 CLAIMS CORRECTION 04 ONLINE REPORTS VIEW ENTER MENU SELECTION ff PLEASE ENTER DATA OR PRESS TO EXIT NUM Figure 5 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 Palmetto GBA Page 9 February 2008 Section 2 Connection Instructions DDE User s Manual for Medicare Part A 2 The screen will display SESSION SUCCESSFULLY TERMINATED NORTH CAROLINA 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 GULF COAST MIDWEST SIGN OFF Type CSSF LOGOFF over the message and press ENTER SOUTHEAST SOUTHWEST SIGN OFF Type CSSF LOGOFF over the message and press ENTER 3 Pull down the Terminal menu from the toolbar and select Disconnect
123. eer OR IHRE EH REALE ER URL Aon HERE AEA SE NE a 124 MOH P388 9i pu dmt cce tine tiviic dex istas Doro errr errr den mate tons tere rent preter 125 HIOH Pase 6s Page T i Poeta eir eate rive ibo etd eb eri E EHE EEUU erbe EE iat es 126 APPENDIX ACRONYMS 127 The information provided in this manual was current as of February 2008 Any changes or new information superseding the information in this manual are provided in the Medicare Part A Bulletins Advisories with publication dates after February 2008 Medicare Part A Bulletins Advisories are available at www PalmettoGBA com Palmetto GBA Page iii February 2008 DDE User s Manual for Medicare Part A Section 1 Introduction 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 and Claim Correction A DDE Medicare provider may perform the following functions electronically Type and send UB 04 claims Correct adjust and cancel claims Inquire about patients eligibility Access the Revenue Code HCPCS Code and ICD 9 Code inquiry tables Access the Reason Code and Adjustment Reason Code inquiry tables 9 9 9
124. en displays specific claim history information for all pending RTP claims MSP claims Medical Review claims and processed 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 P B7501 Post Pay Review P B7505 Post Pay Review R 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 FISS loca
125. er s Manual for Medicare Part A From the Online Reports Menu you can select R1 for a summary of reports from which you can select one Figure 47 or R2 view a report by entering the report number Figure 48 MAPnnnn MEESDEETECEASHEEREANOSNISETETNIIEMESYM S EM ONLINE REPORTS SELECTION REPORT NO SEL REPORT NO FREQUENCY DESCRIPTION 201 WEEKLY CLAIM PENDING REPORT PROCESS COMPLETED NO MORE DATA THIS TYPE PLEASE MAKE A SELECTION ENTER NEW KEY DATA OR PRESS PF3 TO EXIT Figure 47 Ri Summary of Reports Online Reports Selection Field Name Description REPORT NO 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 Valid values are Daily Weekly and Monthly DESCRIPTION Identifies the name or title of the report MAPnnnn REPORT FREQUENCY SCROLL KEY PAGE SEARCH PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 48 R2 View A Report Page 100 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 7 Online Reports 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 pr
126. er 1 ID field PAT 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 PAT RESP Patient Responsibility identifies the amount for which the individual receiving services is responsible The amount is calculated as follows Ifthe Payer 1 indicator is C or Z then the amount will equal Cash Deductible Coinsurance Blood Deductible Ifthe Payer 1 indicator is not C or Z then the amount will equal MSP Blood MSP Cash Deductible MSP Coinsurance PAT 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 PROV REIMB The Provider Reimbursement amount determined by the system This is the calculated line item amount 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 REIMB This is the total Medicare Reimbursement for the line item It will be the sum of the Patient Reimbursement and the Provider Reimbursement CONTR ADJUSTMENT The following calculation will be performed to obtain the t
127. eview 03 Paid 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 for transfers without an approved outlier Palmetto GBA Page 33 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name Description 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 Return codes 50 99 describe why the bill was not priced 51 No provider specific information found 52 Invalid MSA in provider file 53 Waiver State not calculated by PPS 54 DRG not 001 468 or 471 910 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 60 Review code 02 and length of stay indi
128. f stay days may exceed Pricer covered days in the non outlier portion of the stay Palmetto GBA February 2008 Page 31 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name COV DAYS Description 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 CWE 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 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 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 Field Name Description 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 o
129. f 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 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 RTN CD The
130. fferentiate between plans that share a processing site This code will always be a 1 1 1 Century Code Code used to indicate the century in which the DCN was established Valid values include 21900 1999 2 2000 2 3 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 Sequence Primary sequencing field beginning with 0000 and ending with 9999 This is system generated with automated DCN assignment 11 12 Claim Sequence Secondary sequencing field beginning with 00 and ending with 99 13 Split Demo Site specific field used on split bills Valid values include Indicator C Medicare Choices Claim E ESRD Managed Care V VA Demo P Encounter Claim 0 When not used at a site 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 21 Reserved Used in the Home Health A B shift automated adjustment Valid valued include H in first position System generated Trailer 16 adjustment P in second position System generated Trailer 15 adjustment
131. first initial Sex M or F Date of birth in MMDDYYY Y format TAB to move between fields on the screen Only press ENTER when all fields have been completed BENEFICIARY CWF SCREENS Page 1 Field descriptions are provided in the table following Figure 8 MAPnnnn MEESDETSCEASREESPASNOSNEISETENEESESSYESSIEESM XX 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 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 PLEASE ENTER DATA HIC LN FN SEX AND DOB PRESS PF3 EXIT PF8 NEXT PAGE Figure 8 Beneficiary CWF Page 1 Field Name Description HIC Type the patient s health insurance claim HIC number as it appears on the Medicare ID card Page 14 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Field Name Description 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 TRANSFERHIC This field is no longer in use C IND Century Indicator This field represents a one position cod
132. for 60 days 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 Claim Summary Inquiry screen Palmetto GBA Page 95 February 2008 Section 6 Claim Correction DDE User s Manual for Medicare Part A NOTE This action CANNOT be reversed 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 ADJUSTMENTS When claims are keyed and submitted through DDE for payment consideration the
133. for Medicare requirements only Other payers may require codes not reflected Refer to your UB 04 Manual for valid values CERT SSN 60 A B Enter the patient s Health Insurance Card Number HICN if Medicare is HIC ID C the primary payer SEX The sex of the beneficiary patient Refer to your UB 04 Manual for valid values Page 82 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry UB 04 Field Name X Ref Description GROUP NAME 61 A B Enter the name of the group or plan through which that insurance is C provided Entry required if applicable DOB The insured s date of birth in MMDDCCYY format INS GROUP 62 A B Enter the Insurance Group identification number control number or code NUMBER C assigned by that health insurance company to identify the group under which the insured individual is covered Entry required if applicable Enter the code that indicates whether the employment information given on the same line in items 72 75 applies to the insured the patient or the patient s spouse TREAT AUTH 63A B The HHPPS Treatment Authorization Code identifies a matching key to CODE C the OASIS Outcome Assessment Information Set of the patient This field is 2 8 digit dates MMDDCCY YMMDDCCYY followed by a 2 digit code 01 10 The first date comes from M0030 that is the Start of Care Date the second date is from M0090 that is the Dat
134. for approval Prior to SEND Intermediary 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 CWE 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 CWF Disposition Code a 2 digit category or status of claim that indicates e Claim is approved e Claim is rejected e Claims will be retrieved from history Alert codes CWF requests for investigation of overlapping benefits and eligibility status Page 108 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 8 Health Insurance Query Access Approved claims Intermediary produced provider check and remittance advice Rejected claims that require further investigation Intermediary reviews these claims makes corrections and resubmits them to CWF
135. he AT amp T Global Network Client shortcut icon on your desktop If you are unable to locate the AT amp T Global Network Client icon you can select Start from the Windows Taskbar Programs AT amp T Global Network Client and then AT amp T Global Network Client 3 The AT amp T Global Network Client will open and is ready for your password Verify your Login Profile enter your initial password and then click connect The About window will close From the Passport A toolbar pull down the Terminal menu and click Connect 4 Once you are connected the AT amp T Global Network Client connection status window will display Note You may minimize this window but do not close it until you are ready to disconnect 5 After connecting to the AT amp T Global Network Client click on the Passport IP icon from your desktop If you are unable to locate the Passport IP icon you can select Start from the Windows Task BAR and select Programs AT amp T Passport for Windows and Passport IP 6 From the Passport IP Communications Window choose Terminal from the Main menu and then Connect 7 Once you have a connection established to AT amp T through Passport IP the Product Selection Screen will display Palmetto GBA Page 5 February 2008 Section 2 Connection Instructions DDE User s Manual for Medicare Part A NORTH CAROLINA SIGN ON A At the PRODUCT SELECTION screen your cursor will be positioned at the arrow gt
136. he 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 additions such as interest HOSPITAL SPEC The hospital portion of the total blended payment PORTION FEDERAL SPEC The Federal portion of the total blended payment PORTION Page 34 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description 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 PROV REIM The actual payment amount to the provider for this claim This will be the amount on the Remittance Advice Voucher PRICER VER The program version number for the Pricer program used Claims Summary Inquiry Select option 12 from the Inquiry Menu to access the Claims Summary Inquiry screen The Claims Summary Inquiry scre
137. he 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 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 Palmetto GBA Page 91 February 2008 Section 6 Claim Correction DDE User s Manual for Medicare Part A CLAIM SUMMARY INQUIRY Once an option is chosen from the Claim and Attachments Correction Menu the Claim Summary Inquiry screen Figure 43 will display MAPnnnn HED T GARE A ONLEUNIE SYST le XX CLAIM SUMMARY INQUIRY NPI HIC PROVIDER nnnnnn SAEC TOB OPERATOR ID FROM DATE TO DATE DDE SORT MEDICAL
138. his claim in a 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 MMDDY Y 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 Narrative Displays the reason code s and narrative for the returned claim There is a maximum of 150 occurrences for each reason code narrative 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 51 and 52 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 Page 102 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A
139. ical 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 intermediary number for earliest processed hospital bill with a deductible ADM The Admission Date for the earliest processed hospital bill with a deductible FROM 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 DATE The date the claim was processed by CMS Page 5 Field descriptions are provided in the table following Figure 13 MAPnnnn XX MEESDSTRCEASREERPASSONNEISSTENEESESSYSSSIESM ACCEPTED HH REC CN nnnnnnnnnA NM SMITH ITJ DB 08021919 SX M PAP RSK MAMMO RSK PAP DATE 000000 TECHCOM PROCOM MAMMO DATES 0000 0000 0000 0000 0000 0000 TRANSPLANT INFO COV IND TRAN IND DIS DATE 000000 000000 000000 EPISODE EPISODE DOEBA DOLBA START END 20030501 20030629 20030501 20030503 PROCESS COMPLETED PLEASE CONTINUE PRESS PFS EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 13 Benefici
140. icare Part A Section 9 Health Insurance Query for HHAs HIQH PAGE 5 Field descriptions for Page 5 of the HIQH screen are provided in the table following Figure 67 HIQHCOP CWF HOME HEALTH INQUIRY REPLY PAGE 05 OF 07 HMO REC CN nnnnnnnnnA NM DOE IT J DB 01011911 SX M PLAN OPT EFF DATE TRM DATE PFI INQSCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 67 CWF Part A Inquiry Reply Screen Page 5 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex Valid values are M Male F Female PLAN HMO Identification Code Valid values are 1 H 2 amp 3 State Code 4 amp 5 HMO Number within the state OPT HMO Option Code Describes the beneficiary s relationship with the HMO Valid values are 2 HMO to process bills only for directly provided services and for service from provider with whom the HMO has effective arrangements Palmetto GBA processes all other bills C HMO to process all bills EFF DATE HMO Effective Date TRM DATE HMO Termination Date Palmetto GBA Page 125 February 2008 Section 9 Health Insurance Query for HHAs DDE User s Manual for Medicare Part A HIQH PAGE 6 amp PAGE 7 Field descriptions for Page 6 amp Page 7 of the HIQ
141. iciary 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 MMDDY Y format PRI ENT DT Prior entitlement date for Part A benefits in MMDDY Y format TERM DT Prior termination date for Part A benefits in MMDDY Y format Part B CURR ENT Current Part B benefits entitlement date in MMDDY Y format TERM DT Termination date for Part B benefits in MMDDYY format PRI ENT DT Prior entitlement date for Part B benefits ii MMDDY Y 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 Palmetto GBA February 2008 Page 19 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name Description Current Benefit Period Data FRST BILL DT The date of the earliest billing action in the current benefit period in MMDDYY format LST
142. ider to re bill the service as a separate professional and technical component procedure code The HPSA modifier should only be used with the professional component code and the incentive payment should not be paid unless the professional component can be separately identified 2 Professional component only pay the HPSA bonus S Technical component only do not pay the HPSA bonus 4 Global test only the professional component of this service qualifies for the HPSA bonus payment Action Return the service as un processable and instruct the provider to re bill the service as a separate professional and technical component procedure code The HPSA modifier should only be used with the professional component code and the incentive payment should not be paid unless the professional component can be separately identified D Incident codes do not pay the HPSA bonus 6 Laboratory physician interpretation codes pay the HPSA bonus T Physical therapy service do not pay the HPSA bonus 8 Physician interpretation codes pay the HPSA bonus 9 Concept of PC TC does not apply do not pay the HPSA bonus ANES BASE VAL Identifies the anesthesia base values 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 f
143. ing 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 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 Intermediary that is NUMBER 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 START DATE2 Lists second start
144. ion 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 TYPE Displays the type of claim associated with this reason code Valid values are I Inpatient SNF O Outpatient H Home Health CORF A AIll Claims NARRATIVE The narrative provides a short description for the adjustment reason code Page 48 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry FISS Reason Codes Inquiry Select option 17 from the Inquiry Menu to access the Reason Codes Inquiry screen This screen displays the reason code narrative used for billing errors on the claim and it explains 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
145. ive on January 1 of the year following the year the ESRD beneficiary signed the selection form CWF ICN 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 CONTRACTOR Identifies the carrier or Intermediary 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 record 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 5 True NIF on HCFA Batch System 52 Mater record housed at another CWE site 53 z 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 CI CICS processing error CR Crossover reject ER Consistency edit reject UR Utilization reje
146. iver 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 P Partial reversal F Full reversal the system reverses all charges and days Page 70 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description DEMAND The Medical Review 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 RED The Medical Review Hospice Reduced field identifies for hospice bills the 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 REF The Medical Review Regional Office Referred field identifies for RO Hospice bills if the claim has been referred to
147. l 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 Page 44 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description OVR The override code instructs system in applying the services to the beneficiary deductible and coinsurance Valid values are 0 Apply deductible and coinsurance 1 Do not apply deductible 2 Do not apply coinsurance 3 Do not apply deductible or coinsurance 4 No need for total charges used for multiple HCPC for single revenue code centers 5 RHC or CORF psychiatric M EGHP may only be used on the 0001 total line for MSP N z Non EGHP may only be used on the 0001 total line for MSP Y IRS SSA data match project MSP cost avoided FEE Displays the fee indicator received in the Physician Fee Schedule
148. l non covered charges for all lines not containing a LUAC on MAPI71D 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 z 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 override 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 an
149. laim screen so that you can correct the errors The claim will not transmit until it is free of front end edit errors Correcting Reason Codes e 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 corrections 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 e 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 Page 54 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Note 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 provider number to inquire or input information TAB to the PROVIDER field and type in the provider number To access the Claim and Attachments Entry Menu Figure 31 select option 02 from the Main Menu MAPnnnn PALMETTO GBA CLAIM AND ATTACHMENTS ENTRY MENU CLAIMS ENTRY INPATIENT OUTPATIENT SNF HOME
150. laims 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 Page 22 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name OTHER ENTITLEMENTS OCCURRENCE CD DATE Description The first two occurrence codes and dates indicating another Federal Program or another type of insurance that may be the primary payer Valid occurrence code values include A Working Aged beneficiary or spouse covered by Employer Group Health Plan EGHP B End Stage Renal Disease ESRD beneficiary in 30 month coordination period and covered by employer health plan C Medicare has made a conditional payment pending final resolution D Automobile no fault or other liability insurance involvement E Workers Compensation F Veteran s Administration program public health service or other federal agency program G Working disabled beneficiary or spouse covered by Employer Group Health Plan H Black Lung I Veteran s Administration Program Occurrence Codes Date Definition 1 or 2 Date is the effective date of applicable program involvement A I Date is the date of previous claim where Medicare was determined to be secondary ESRD CD DATE
151. lates 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 zPay 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 D O B The beneficiary s date of birth MMDDY Y Y Y 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 o
152. ll 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 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 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 Intermediary designated by a Uniform Bill Code less than 8 AUTO Claims by bill type which are submitted to the Intermediary in an electronic mode designated by a Uniform Bill Code greater than 7 Palmetto GBA February 2008 Page 107 Section 8 Health Insurance Query Access DDE User s Manual for Medicare Part A SECTION 8 HEALTH INSURANCE QUERY ACCESS The Health Insurance Query Access HIQA gives Medicare providers direct access to the CMS s CWF Host database Providers may query a Beneficiary s Master Record Th
153. 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 Typean S in the SEL field of the desired claim and press ENTER 4 The ADR letter immediately follows claim page 6 MAP 1716 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 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 Intermediary s system This should be referenced when you need to determine The type of revenue codes that are allowed with certain types of bills IfaHCPCS code is required Ifa unitis required Ifarate is required To start the inquiry type in the revenue code about which you are inquiring and press ENTER Palmetto GBA Page 39 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A REVENUE CODE TABLE INQUIRY SCREEN Field descriptions are provided in the table following Figure 19 MAPnnnn HEDICARIE A ONELUENE S 8 1 EIM XX REVENUE CODE TABLE INQUIRY REV CD 0551 EFF DT 070166 IND F TERM DT NARR SKILLED NURS VISIT ALLOW HCPC UNITS RATE EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT Y 070166 Y 070166 N N Y 070166 Y 070166 N N N N Y 070166
154. ment 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 Page 88 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name Description TAXO CD Taxonomy Code This field identifies a collection of unique alphanumeric codes The code set is 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 Indicates an exception to other ESRD data Valid values are SELECTION OR Y Selection Entered on initial selection or for exceptions such as when the CHANGE 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 effect
155. n MMDDYY format LAST BILLED DT Each most recent hospice bill date in MMDDY Y format DAYS BILLED Number of hospice dates used for each hospice period REVO IND The revocation indicator per hospice period Palmetto GBA February 2008 Page 27 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A There are five 5 possible pages of Medicare Secondary Payer MSP CWF information Page 1 is shown in Figure 16 MAPnnnn XX EFFECTIVE DATE TERMINATION DATE MSP CODE NAME ADDRESS HEDUCARE A O NLUNE SYST EIM ACCEPTED MSP DATA PAGE OF SUBSCRIBER NAME POLICY NUMBER INSURER TYPE PATIENT RELATIONSHIP REMARKS CODES INSURER INFORMATION GROUP NO NAME EMPLOYER DATA NAME ADDRESS PROCESS COMPLETED EMPLOYEE ID EMPLOYEE INFO PLEASE CONTINUE PRESS PF3 EXIT PF7 PREV PAGE PF8 NEXT PAGE Figure 16 Medicare Secondary Payer CWF Information Field Name Description EFFECTIVE The date of the Medicare Secondary Payer MSP coverage DATE SUBSCRIBER First and last name of the individual subscribing to the MSP coverage NAME TERMINATION Date the coverage terminates under the payer listed DATE POLICY NUMBER The policy number with the payer listed MSP CODE The type of insurance coverage Valid values are A Working aged beneficiary or spouse covered by employer health plan B End Stage Renal
156. n 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 CORP 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 code see list below on Page 01 of the claim 5 Give a short explanation of the reason for the void cancel in the remarks section on Page 04 of the claim Palmetto GBA Page 97 February 2008 Section 6 Claim Correction DDE User s Manual for Medicare Part A 7 8 To back out without transmitting the void cancel press F3 Any changes made to the screens will not be updated Press F9 to update enter the cancel claim into DDE for reprocessing and payment retraction 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 voi
157. ollowing Figure 38 MAPnnnn MUESDEISCEASDEENPASEOBNEISSTENEESESSYESSIMESM CLAIM PAGE 05 XX CLAIM ENTRY HIC TOB S LOC S PROVIDER INSURED NAME REL CERT SSN HIC SEX GROUP NAME DOB INS GROUP NUMBER TREAT AUTH CODE TREAT AUTH CODE TREAT AUTH CODE REASON CODES PRESS PF3 EXIT PF7 PREV PF8 NEXT PF9 UPDT Figure 38 UB 04 Claim Entry Page 5 z UB 04 eer Field Name X Ref Description INSURED 58 A B Maximum of 25 digits Last Name First Name On the same line that NAME C corresponds to the line on which Medicare payer information is reported 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 A and enter the name of the individual insured under a supplemental policy on line B Complete this section by entering the name of the individual in whose name the insurance is carried if there are payer s of higher priority than Medicare and the provider is requesting payment because Another payer paid some of the charges and Medicare is secondarily liable for the remainder Another payer denied the claim or The provider is requesting conditional payment REL 59 A B On the same lettered line A B or C that corresponds to the line on C which Medicare payer information is reported enter the code indicating the relationship of the patient to the identified insured The following codes are
158. onal 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 Palmetto GBA February 2008 Page 73 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description NCD RESP The National Coverage Determination 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 lin
159. onsin 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 Palmetto GBA Page 119 February 2008 Section 9 Health Insurance Query for HHAs DDE User s Manual for Medicare Part A HIQH Inquiry Screen Once you have successfully logged onto the HIQH function the CWF beneficiary inquiry area will display Figure 62 To access a beneficiary s CWF Master Record enter information into this screen Field definitions and completion requirements are provided in the table following Figure 62 CWF PART A INQUIRY RESPONSE CODE CLAIM NUMBER SURNAME INITIAL DATE OF BIRTH SEX CODE REQUESTOR ID PRINTER DEST INTER NO PROVIDER NO HOST ID APP DATE GL GW KS MA PA NE SE SO SW REASON CODE 1 Field Name Response Code Figure 62 CWF Beneficiary Inquiry Screen 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 in this field Surname Enter the first six 6 letters of the beneficiary s last name Initial Enter the first initial of the
160. or 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 applicable PLAN Data ID CD Plan Identification Code This field identifies the Plan Identification code This is a five position alphanumeric 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 Page 16 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description OPT CD This field identifies whether the current Plan services are restricted or unrestricted Valid values are Unrestricted 1 Intermediary 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 A Intermediary to
161. or the HCPC DESCRIPTION Diagnosis amp Procedure Code Inquiry 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 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 Page 46 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry 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 ICD 9 CM CODE INQUIRY SCREEN Field descriptions are provided in the table following Figure 23 MAPnnnn MEESDETECSASREESSASNONNEISETENIESEMESMYAGSSIEESM XX ICD 9 CM CODE INQUIRY STARTING ICD9 CODE ICD9 CODE DESCRIPTION EFFECTIVE TERM DATE EFFECTIVE TERM DATE EFFE
162. ort Pended Processed and Returned Clabms udi rta siepe Itb Praed ek o imde 102 216 Errors on Initial Billetes cinis tipi Perd pu rivi peritia lav FARE Lue ie SS latura 105 SECTION 8 HEALTH INSURANCE QUERY ACCESS 108 P tt A CWF Send P GOBSE ipiaetitisioninitaf aite fienda ea ena isla Sn MOs EE EEEa 108 Part A Response ProGe85 aeseviedve date o idees a EO A 108 CWE HOSS IE 109 WOA Tg Screens e ean R a a a tui a 109 EHIQA Pagel ous ecrit it TREA I edt d Has dan hea A AAR 110 HIOA PARC EE 112 IQA Page c 114 HIQA Page EUM 115 HIQA Page 5 iio nitet tee Ea H PEE HP ERE RETE EXER HARE GEHE REP Ee EE RI Pro Sede 116 HIOA Pace Girora toro Roe ri etisalat chai ibo Hades p ebd EP ordin 117 Page ii Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Table of Contents SECTION 9 HEALTH INSURANCE QUERY FOR HHA 118 Pare AC WE Send Process opinar fron nv m MD rp I eS 118 Part A Response PrOCOSS ao d pevceti oi roe vn a be ip b sai saspe qe QE be Pet dde is Mid bm ossia R 118 CWE Host cT 119 HIOH nays STSCI EE E o o 0o S 0T TEST 120 HIOLB Page Letti dieere sous cites cuca swe rot eee iba rie vete Die inima ties Fir Sees EE penis rb es retbs dorus eden aeo ed 121 HION PIS 9i ettet tis dotis tee isi a a 122 ENLO i DN 123 HIOP Page d e ioteten i te re eee
163. ot required TERM ILL IND Page 78 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description IDE Identifies the Investigational Device Exemption IDE authorization number assigned by the FDA PROCEDURE CODES AND DATES 79 81 Enter the full ICD 9 CM including all four digit codes where applicable for the principal procedure first code Enter the date in MMDDYY format that the 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 REASON CODE Not required for new claim entry Adjustment reason codes are applicable only on adjustments TOB nn7 and nn8 REJECT CODE Not required by provider For Intermediary use only NON PAY CODE Not required by provider For Intermediary use only ATT PHYS 82 Enter the Unique Physician Identification Number UPIN and name of the attending physician for inpatient bills or the physician that requested the outpatient services Inpatient Part A Enter the UPIN and name of the clinician who is primarily and largely responsible for the care of the patient from the beginning of the hospital episode Enter the UPIN in the first six digits followed by two spaces the last name one space the first name one sp
164. otal 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 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 OUTLIER Identifies the apportioned line level outlier amount returned from MSPPAYOL PRICER AMT The Pricer Amount provides the line item reimbursement received from a pricer Palmetto GBA February 2008 Page 65 Section 5 Claim Entry DDE User s Manual for Medicare Part A UB 04 X Ref 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 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 appr
165. oved 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 Field Name Description 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 471 910 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 60 Review code 01 and length of stay indicates day outlier Bill is not eligible as cost outlier 61 Lifetime reserve days not numeric 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 specifi
166. oviders 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 49 and 50 MAPnnnn REPORT 050 FREQUENCY D KEY nnnnnn PAGE 000001 SEARCH REPORT MEDICARE PART A 00 CYCLE DATE CLAIMS RETURNED TO PRO PROVIDER FOR CYCLE DATE nn nn FOR PROVIDER HIC CERT SSNO PCN DCN TYPE BILL PROVIDER NAME C7080 OUTPATIENT CLAIMS DATES OF SERVICE ARE EQUAL OR OV FROM DATE AND THRU DATES OF THE ADMISSION FOR INPA PROVIDERS REFUND ANY COLLECTED PART B DEDUCTIBLE AND OR COINSURANCE AND BILL THE INPATIE SERVICES IF SERVICE DATES ARE INCORRECT CORRECT TOTAL RETURNED CLAIMS ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 49 050 Claims Returned to Provider Scroll Left View MAPnnnn REPORT 050 FREQUENCY D KEY nnnnnn PAGE 000001 SEARCH REPORT 050 101 PAGE CYCLE DATE nn nn nn VIDER FREQUENCY PROVIDER 000000 98 RUN TIME 18 116 FOR PROVIDE E THE SERVICES WERE ADMIT COV FM COV TO TOTAL CHGS nnnnnnnnnA nnnnn ONE nnnnnn nnnnnn nnnnnn 1332176 nnnnn ERLAP OR ARE WITHIN THE TIENT FOR DIFFERENT NT PROVIDER FOR THESE AND RESUBMIT WITH OCCURRENCE SPAN CODE IN WHICH THIS OUTPATIENT TOTAL RETURNED CLAIM nn nnn nn ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF10 LEFT Figure 50 050 Claims Returned to Provider Scroll Right View
167. 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 the ENTER key the system will display the message Your password has expired Please enter your new password The screen will now contain one New Password field Page 10 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 2 Connection Instructions 2 Your cursor will be 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 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 1 2 Proceed to the CDS EDC TPX session screen P
168. presents 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 CTRLHR press the letter R This will reset the screen Note Do not use this key combination if you see the clock symbol X displayed at the bottom of the screen see next term One of these symbols displays at the bottom of the screen when the system is X processing your request Do not press any key until the symbol goes away and the blinking cursor returns 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 END Palmetto GBA Page 1 February 2008 Section 1 Introduction DDE User s Manual for Medicare Part A 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 F2 Revenue Code Jump From claim page 3 MAP1033 press F2 to jump to MAPI71D for the first Revenue Code in error Also if your cursor is placed on a specific Revenue Code line on page 3 press F2 to jump to the same
169. 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 MMDDY Y format of the beneficiary s effective period 1 4 with the Hospice Provider PROVIDER A 13 character alphanumeric field that identifies each hospice provider INTER A 6 character alphanumeric field that identifies each Intermediary number for the hospice Provider 1 4 TERM The termination date of a beneficiary s election period 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 Intermediary 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 A 13 character alphanumeric field that indicates each identification number of the 2nd hospice provider INTER A 6 character alphanumeric field that identifies each Intermediary number for the 2nd hospice provider 1 4 TERM DT A 6 digit numeric field that identifies each termination date for hospic
170. ption IP REC CN Claim number being investigated NM Last name of the beneficiary Up to six characters may be used in this field IT First initial of the beneficiary SX Sex of the beneficiary EPISODE The start date of an episode START EPISODE END The end date of an 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 HIQA PAGE 6 Field descriptions for Page 6 of the HIQA screen are provided in the table following Figure 61 HIQA HIQACOP IP REC PROCEDURE HCPCS CODE PF1 INQ SCREEN PF3 CLEAR END Figure 61 CWF Part A Inquiry Reply Screen Page 6 CN nnnnnnnnnA CWF PART A INQUIRY REPLY PAGE 06 OF 06 NM DOE IT J DB 01011911 SX M DESCRIPTION TECH PROF RICK MOST RECENT DATES OF SERVICE PFS NEXT Field Name Description IP REC CN Claim number being investigated NM Last name of the beneficiary Up to six characters may be used in this field IT First initial of the beneficiary SX Sex of the beneficiary PROCEDURE DESCRIPTION HCPCS Code Healthcare Common Procedure Coding System HCPCS code for Mammography TECH Technical Service of Mammography PROF Professional Service of Mammography RISK Not Used Most Recent Dates Of Service Date of service for the HCPCS Technical and Professional codes Palmetto GBA February 2008
171. r 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 FIs as well as the MSA by Provider This field is system filled REDUCED COINSURANCE For all services subject to OPPS TOB 12n 13n 14n and 76n the amount of Patient Reduced Coinsurance applicable to the line for a particular coinsurance amount Providers are only permitted to reduce the coinsurance amount due from the beneficiary for services paid under OPPS and the reduced amount cannot be lower than 20 of the payment rate for the line If the provider does not elect to reduce the coinsurance amount the field will contain zeros Page 62 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description ESRD The Patient End Stage Renal Disease Reduction Psychiatric RED PSYCH Reduction Hemophilia Blood Clotting Factor will notate one of three HBCF 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
172. r 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 tow 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 MMDDY Y format TO DATE Type the To Date of service you want to view in MMDDY Y 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 Review Select This field is used to narrow the claim selection for inquiry This provides the ability to view only claims pending or returned for medical review Note This field is only accessible in Claims Correction mode Page 36 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry Field Name Description 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 appears this field is blank First Line Of Data HIC Patient s health insuranc
173. r 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 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 z 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 Contra
174. rd copy paper and peer review organization claims This is the path DDE will follow Press F8 on the Reason Codes Inquiry screen to display the ANSI Related Reason Code Inquiry screen Figure 27 This screen provides the ANSI reason code equivalent to the FISS reason code Press F7 to return to the Reason Codes Inquiry screen Page 50 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry MAPnnnn XX NEES Dein C eA Re Es Ass ORNS IES NG ERSS TIEM ANSI RELATED REASON CODES INQUIRY REASON CODE C7010 PIMR ACTIVITY CODE PCA INDICATOR DENIAL CODE 100003 LMRP NCD ID ANSI CODES ADJ REASONS B9 GROUPS REMARKS APPEALS A MA02 MA13 APPEALS B MA01 MA13 CATEGORY EMC F2 HC F2 STATUS EMC 0188 HC 0188 PRESS PF3 EXIT PF7 PREV PAGE Figure 27 ANSI Related Reason Codes Inquiry Screen ANSI Reason Code Inquiry OP MAnnnn DT 040503 MR INDICATOR 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 specific ANSI reason code and press ENTER
175. re enter the UPIN and name of the physician who performed the surgical procedure most closely related to the principal diagnosis 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 Palmetto GBA February 2008 Page 79 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name ee Description NPI This field identifies the National Provider Identifier number LN This field identifies the last name of the operating physician FN This field identifies the first name of the operating physician MI This field identifies the middle initial of the operating physician OTH PHYS This field identifies the name and or number of the assisting licensed physician NPI This field identifies the National Provider Identifier number LN This field identifies the last name of the other physician FN This field identifies the first name of the other physician MI This field identifies the middle initial of the other physician UB 04 CLAIM ENTRY PAGE 4 The Remarks Page Figure 37 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
176. reater 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 z Office of Personnel Management OPM Data Match Contractor 11113 14 Workers Compensation WC Data Match Contractor 11114 GENER Instructs the system 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 COMP that 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 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 z Medical records received This service received complex manual medical review N z Medical records were not received This service received routine manual medical review TPE
177. red 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 you wish to 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 DATE OF The date the service was rendered to the beneficiary in MMDDYYYY format SERVICE TYPE OF BILL Type the type of bill for the submitted roster bill 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 Healthcare Common Procedure Coding System HCPCS applicable to ancillary services Valid values are G0008 Q0124 and 90724 CHARGES PER BENEFICIARY Enter the charges per revenue code being charged to the beneficiary Patient Information HIC The health insurance claim number assigned when a beneficiary
178. reen Right Moves right to columns 81 132 Page 2 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 1 Introduction 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 information 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 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 FISS S LOC Codes
179. res Any usage of this system may be monitored recorded and audited Any unauthorized use of this system is prohibited and subject to criminal and civil penalties Any use of this systems constitutes consent to any and all monitoring and recording of the user s activities PF ESEnd Figure 3 Companion Data Service Sign On Screen Palmetto GBA Page 7 February 2008 Section 2 Connection Instructions DDE User s Manual for Medicare Part A GULF COAST MIDWEST SIGN ON A At the PRODUCT SELECTION screen your cursor will be positioned at the gt in the lower left hand corner of the screen Type the number corresponding to option GCDDE and press ENTER B Press ESC or Scroll Lock to clear the screen C On the blank screen type CSSN and press ENTER D The Sign On screen Figure 4 will display SOUTHEAST SOUTHWEST SIGN ON A At the PRODUCT SELECTION screen your cursor will be positioned at the gt in the lower left hand corner of the screen Select the number corresponding to option CARESC and press ENTER S Press ESC or Scroll Lock to clear the screen On the blank screen type CSSN and press ENTER 2n The Sign On screen Figure 4 will display CICS SIGN ON 775 b TRM 22701 Terminal Di Figure 4 The Sign On Screen 13 At the USERID prompt type your DDE User ID and press TAB DDE User ID numbers are assigned to individuals at each facility who utili
180. ress the PF5 key 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 Press ENTER A message will appear at the bottom of screen providing the new temporary password Press PF12 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 e The password length must be eight 8 characters e Passwords must have at least one 1 of these special characters or e Passwords must start with a letter and must have at least one 1 number and one 1 letter not a number of special character NOTE A password can only be reset by the user with this process once in a 24 hour period Palmetto GBA Page 11 February 2008 Section 3 Main Menu DDE User s Manual for Medicare Part A SECTION 3 MAIN MENU The DDE Online system includes the Main Menu Figure 6 that displays after completing the logon procedure Each menu option from the Main Menu displays a sub menu for that option Note Palmetto GBA does not utilize Main Menu Option 04 Online Reports View MAPnnnn PALMETTO GBA MAIN MENU INQUIRIES CLAIMS ATTACHMENTS CLAIMS CORRECTION ONLINE REPORTS VIEW ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 6 The Main Menu The Inquiries 01 Claims Attachments 02 and Claims Correction 03 sub menus are explained in
181. rt B Termination Indicates date of termination of Part B entitlement in MMDDY Y format 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 HIQH PAGE 2 Field descriptions for Page 2 of the HIQH screen are provided in the table following Figure 64 HIQHCOP HH REC SPELL NUM 02 01 CN nnnnnnnnnA QUALIFYING HOME HEALTH BENEFIT PERIOD PAGE 02 OF 07 NM DOE IT J DB 01011911 SX M LATEST BILLING PARTB VISITS APPLIED PARTA VISITS REMAINING EARLIEST IND BILLING 82 46 07 15 2003 9 19 2003 09 12 2003 0 03 20 2001 0 0 0 PF1 INQ SCREEN PF3 CLEAR END PF7 PREV PF8 NEXT Figure 64 CWF Part A Inquiry Reply Screen Page 2 Field Name Description CN Claim Number Shows the beneficiary s HIC number NM Name Shortened form of the beneficiary s surname IT Initial First letter of beneficiary s first name DB Date of Birth Beneficiary s eight digit date of birth SX Sex Beneficiary s sex Valid values are M Male F Female 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 IND A B split hospitalization Valid values
182. s UB 04 X REFs 32 35 and or occurrence span code UB 04 X REF 36 Provide a brief explanation of any non covered days not described via occurrence codes in UB 04 X REF 84 Remarks Show the number of days for each category of non covered days e g 5 leave days Day of discharge or death is not counted as a non covered day Do not deduct days for payment made by another primary payer Palmetto GBA February 2008 Page 57 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description CO 9 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 LTR 10 Lifetime Reserve Days This field only used for hospital inpatient stays Enter the total number of inpatient lifetime reserve days the patient elected to use during this billing period LAST 12 Patient s last name at the time services were rendered FIRST 12 Patient s first name MI 12 Patient s middle initial DOB 14 The patient s date of birth in MMDDY Y YY format ADDR 13 Patient s street address Must input in fields 1 and 2 State is a 2 character 1 2 3 4 5 6 field ZIP 13 Valid zip code minimum of 5 digits DOB The patient s date of birth in MMDDYYYY format SEX 15 The patient s sex Refer to
183. s Related Grouping E EGHP Employer Group Health Plan EMC Hlectronic Media Claims ERA Electronic Remittance Advice ESRD End Stage Renal Disease F FDA Food and Drug Administration FI Fiscal Intermediary FISS Fiscal Intermediary Standard System FMR Focused Medical Review FQHC Federally Qualified Health Centers G H HCFA Health Care Financing Administration now CMS HCPC Healthcare Common Procedure Code HCPCS Healthcare Common Procedure Coding System HHA Home Health Agency HMO Health Maintenance Organization IDE Investigational Device Exemption IEQ Initial Enrollment Questionnaire IME Indirect Medical Education IRS Internal Revenue Service J K L M MCE Medicare Code Editor MR Medical Review MSA Metropolitan Statistical Area MSN_ Medicare Summary Notice MSP Medicare Secondary Payer N NDC National Drug Code O OCE Outpatient Code Editor OMB Office of Management and Budget OTAF Obligated To Accept in Full P PHS Public Health Service PPS Prospective Payment System PRO Peer Review Organization Q R RA Remittance Advice RHC Rural Health Clinic RTP Return To Provider S SNF Skilled Nursing Facility SSA Social Security Administration T U UPIN Unique Physician Identification Number UR
184. 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 Page 72 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name UB 04 X Ref Description 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 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 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 claims 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 Nati
185. spice s Medicare provider number INTER The second hospice s Intermediary number 1ST BILLED DT The date of each earliest hospice bill date Gn MMDDYY format LAST BILLED DT Each most recent hospice bill date Gn MMDDYY format DAYS BILLED Number of hospice dates used for each hospice period REVO IND The revocation indicator per hospice period 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 in MMDDYY format PROV The hospice s Medicare provider number INTER The hospice s Intermediary 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 Intermediary number 2ND START DATE The date the second benefit period began PROV The second hospice s Medicare provider number INTER The second hospice s Intermediary number TERM 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 Intermediary number 1ST BILLED DT The date of each earliest hospice bill date G
186. st 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 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 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 z Workers Compensation X MSP cost avoided Page 68 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 5 Claim Entry Field Name Description Y IRS SSA Data Match Project MSP Cost Avoided Contractor 71777 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 g
187. 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 Check History Inquiry Select option FT 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
188. t this field will contain an asterisk otherwise it will be blank 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 cz Location code positions 2 amp 3 is 80 or 85 CWER Location code positions 2 amp 3 is 90 CWF Regular Location code position 4 is not B F J L or M CWED 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 Page 104 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 7 Online Reports Field Name ADS Description Addition 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 a
189. t 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 CI CICS processing problem SV Security violation MSG Message The verbiage pertaining to the disposition code CORRECT Correct Claim Number Use only if HIC number is incorrect NM Corrected Name Used only if the name is not consistent with CMS s record IT Corrected Initial Used only if the initial is not consistent with CMS s record DB Corrected Date of Birth Used only if the date of birth entered is different than CMS s beneficiary record Palmetto GBA February 2008 Page 121 Section 9 Health Insurance Query for HHAs DDE User s Manual for Medicare Part A Field Name Description SX Corrected Sex Codes Used only if sex code is not consistent with CMS s record A ENT Part A Entitlement Date of entitlement to Part A benefits This is ina MMDDYY format A TRM Part A Termination Indicates date of termination of Part A entitlement This is in a MMDDYY format B ENT Part B Entitlement Date of entitlement to Part B benefits in MMDDYY format B TRM Pa
190. t the medical facility NBR ADS 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 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 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
191. tandard 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 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 Calcu
192. ter toll free at 1 866 749 4301 for assistance 10 After you correctly enter your User ID and password the TPX Menu Screen Figure 2 will display Page 6 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 2 Connection Instructions TPX MENU FOR Panelid TEN0041 Terminal S6003856 AEE A 1 Nenu Model 3292 5A Cmdchar Systen ASPTPX Sesskey Session Description Status FSSPHC PF NC Part A Prod FSSPHC2 PF HC Part A Prod FSSUNC PF HC Part A UAT FSSUNC2 PF MC Part A UAT TPXADMIN PF TPX Administration TSOEDCA PF TSO edca Command gt PF ISERE F 78 o F o2 O SE F 1 0 22 RM 11022 ECL LL Figure 2 TPX Menu Screen 11 Select the NC Part A Prod Session from the menu with an S indicator on the line and Press Enter 12 After your selection from the TPX menu the Companion Data Services Sign On Screen Figure 3 will display At the USERID Prompt type the same DDE User ID and password used previously on the TPX Sign On Screen TS00P420 TS00M42 Companion Data Services LLC 02 25 09 55 Type your userid and password Password New Password Verify New Password gt Note Parts of this computer system may be owned by the United States Government If so the Centers for Medicare and Medicaid Services CMS maintains ownership and responsibility for those parts Users of this system must adhere to CMS Information Security Policies Standards and Procedu
193. 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 adjustments CHARGES at the end of the processing cycle 316 Errors on Initial Bills The Errors on Initial Bills report Figures 53 and 54 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 February 2008 Page 105 Section 7 Online Reports DDE User s Manual for Medicare Part A MAPnnnn REPORT 316 FREQUENCY W KEY nnnnnn PAGE 000001 SEARCH REPORT 316 MEDICARE PART A 00 CYCLE DATE 10 31 03 ERRORS ON INITIAL BI PROVIDER nnnnnn REASON INPAT SNF HHA OUTPAT HOSP ESRD LCF E CODE H C AUTO H C AUTO H C AUTO H C AUTO H C AUTO H C E94G2 0 0 0 1 0 13599 15331 15431 16602 16603 30924 31023 31616 32300 32303 32402 rali 37192 39700 0 0 0 ENTER NEW KEY DATA OR PRESS PF2 SEARCH PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF11 RIGHT Figure 53 316 Errors on Initial Bills Scroll Left View Gm Co C Co CQ CO CO CO CO CO CD C c Soo eo ea eS oa ere isi OES lS SOS OS Oro
194. the PROVIDER field If the facility has multiple provider numbers you will need to change the provider number to inquire or input information TAB to the PROVIDER field and type in the provider number Page 42 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 4 Claim Inquiry CHECK HISTORY SCREEN Field descriptions for the Check History screen are provided in the table following Figure 21 MAPnBnn MEESDETRCSASREERPAGNONNSEISSTENISESESSYASSIEESM XX CHECK HISTORY PROV nnnnnn CHECK DATE AMOUNT PLEASE ENTER DATA OR PRESS PF3 TO EXIT Figure 21 Check History Screen Field Name Description PROV The Medicare assigned provider number CHECK The last three payments issued to the provider by Medicare Leading zeros indicate a check EFT indicates electronic fund transfer DATE The date when the payments were issued AMOUNT The dollar amount of the last three payments issued to the provider 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 HCPC
195. the revenue code line item being denied ADR REASON CODES 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 narrative as they appear on each revenue code line FMR REASON CODES 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 ODC REASON CODES This field identifies original denial reason codes ORIG Identifies the original HCPC billed and modifiers billed accommodating a 5 digit HCPC and up to 5 2 digit modifiers ORIG REV CD Identifies the Original Revenue Code billed MR This field indicates if the service received complex manual medical review The valid values are The
196. tion 4 Claim Inquiry DDE User s Manual for Medicare Part A Field Name PROVIDER Description Automatically filled with the provider number but accessible if the provider is authorized to view other provider numbers S LOC The status location of the claim can be used as search criteria CAT The category can be used as search criteria 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 anda 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 NMz 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 this category are not included in the total count TC category AD Adjustments Within each
197. tion codes Palmetto GBA Page 35 February 2008 Section 4 Claim Inquiry DDE User s Manual for Medicare Part A CLAIMS SUMMARY INQUIRY SCREEN Field descriptions for the Claim Summary Inquiry screen are provided in the table following Figure 18 MAPnnnn XX HIC OPERATOR ID DDEDKA MED UGARIE A ONE ur NERS VY 8S a le CLAIM SUMMARY INQUIRY NPI PROVIDER nnnnnn FROM DATE S LOC TOB TO DATE DDE SORT MEDICAL REVIEW SELECT HIC SEL LAST NAME PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT 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 18 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 correct 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 fo
198. ue 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 February 2008 Page 71 Section 5 Claim Entry DDE User s Manual for Medicare Part A Field Name UB 04 X Ref Description HCPC MOD IN 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 Identifies the HCPC code that further defines the revenue code being submitted The information on this field was entered on MAPI712 MODIFIERS Identifies the HCPCS modifier codes for claim processing This field may contain five 2 position modifiers SERV DATE The line item date of service in MMDDYY format and is required for many outpatient bills This information was entered on MAPI712 COV UNT The number of covered units associated with the revenue code line item being denied COV CHRG The number of covered charges associated with
199. ull 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 I Full Provider liability medical not subject to waiver provisions J Full Provider 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 z The Provider does have their waiver status N The Provider does not have their wa
200. 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 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 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 T RTP claims D Medically denied claims Type of Bill nnP PRO adjustment or nnl intermediary adjustment If a claim has been denied with a full or partial medical denial the provider cannot submit an adjustment Any attempted adjustments will reject with Reason Code 30904 a provider is not permitted to adjust a partially or fully medically denied claim 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
201. usly 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 adjustment system and update a claim without making the right corrections the cancel will still be created and process through the system Errors could cause payment to be taken back unnecessarily In addition 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 Do not cancel TOB XXP PRO adjustments or XXI Intermediary Adjustments A cancel bill must be made to the original paid claim Providers may not reverse a cancel Errors will cause payment to be taken back by the Intermediary 9 9 Provider 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 locatio
202. y the ASC Pricer in its calculation for the indicated revenue code UB 04 CLAIM ENTRY PAGE 2 MAP171D This page is a copy of core claim MAP1093I claim page 32 Providers may only view this page No additions modifications or deletions may be made here Field descriptions for this screen are provided in the table following Figure 35 Palmetto GBA Page 67 February 2008 Section 5 Claim Entry DDE User s Manual for Medicare Part A MAPnnnD XX DCN STATUS HEDUGARIE A ONLGUNE SWS 7 E ih ells HAE Oz LOCATION PROVIDER ID NONPAY CD TPE TO TPE REJ CD CLAIM ENTRY HIC RECEIPT DATE TOB TRAN DT STMT COV DT TO BENE NAME GENER HARDCPY MR INCLD IN COMP CL MR IND USER ACT CODE WAIV IND MR REV URC DEMAND MR HOSP RED RCN IND MR HOSP RO ORIG UAC MED REV RSNS OCE MED REV RSNS HCPC MOD IN SERV REV HCPC MODIFIERS DATE COV UNT COV CHRG ADR ORIG OCE OVR TOTAL 30715 FMR ORIG REV MR ODC CWF OVR NCD OVR NCD DOC NCD RESP NCD OLUAC NON LUAC COV UNT NON DENTAL OVER ST LC MED COV CHRG REAS CODE OVER TEC ADJ GRP LINE ITEM REASON CODES lt REASON CODES PRESS PF2 1712 PFS3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF10 LEFT Figure 35 UB 04 Claim Entry Page 2 MAP171D Field Name eer Description PROVIDER ID Identifies the identification number of the Provider submitting the claim BENE NAME The name of the Beneficiary 20 positions for the la
203. your UB 04 Manual for valid values MS 16 The patient s marital status Not required Refer to your UB 04 Manual for valid values ADMIT DATE 17 Enter date patient was admitted HR 18 Enter the hour the patient was admitted for hospitals only TYPE 19 The type of admission Enter the appropriate inpatient code that indicates the priority of the admission This is not required for SNFs or outpatient facilities Refer to your UB 04 Manual for valid values SRC 20 The source of admission Enter appropriate code indicating the source of this admission Refer to your UB 04 Manual for valid values D HM 21 Enter the time at which the patient was discharged from inpatient care in HHMM format STAT 22 Indicates the patient s status at the ending service date in the period Refer to your UB 04 Manual for valid values COND CODES 24 30 The condition codes are used to identify conditions relating to this bill that may affect claim processing up to 30 occurrences Refer to your UB 04 Manual for valid values OCC CDS 32 The Occurrence Codes and Dates field consists of a two digit alphanumeric DATE 35 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 SPANCODE 36 Enter the appropriate Occurrence Span and Date code and associated DATES beginning From and ending Thru dates defining a specific event relating to this billing period Refer
204. ze the DDE system 14 At the 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 Page 8 Palmetto GBA February 2008 DDE User s Manual for Medicare Part A Section 2 Connection Instructions 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 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 call the Palmetto GBA EDI Technology Support Center toll free at 1 866 749 4301 If you have not used DDE for several months it may be automatically revoked Instructions listed below are for all providers North Carolina Gulf Coast Midwest and Southeast South west 15 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 giv

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