DDE Training Manual Fiss_guide

8/19/2019 DDE Training Manual Fiss_guide

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March 2012

Fisc al In term ed iary Stan d ardSy s tem (FISS)

Trainin g Manu al


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Fiscal Intermediary Standard System (FISS) Training Manual

March 2012

An Important Notice to Users of This Manual

Novitas Solutions, Inc. Provider Outreach and Education has produced this manualto assist providers that have access to the Fiscal Intermediary Standard System

(FISS). This manual does not include billing information.

Novitas Solutions, Inc. Provider Outreach and Education makes every effort toensure that the material in this manual is accurate and current. However, since theMedicare program is constantly changing, it is the responsibility of each provider toremain abreast of changes in the Medicare program.

This manual serves as a reference and is ideal for users (both experienced andinexperienced) of the Fiscal Intermediary Standard System (FISS). It providesguidance on how to enter information onto the claim pages associated with theuniform bill (UB04) claim form. The manual also provides field descriptions of the

FISS and Health Insurance Query Access (HIQA) Screens.To have a pleasant experience of working with the FISS and the Manual you will seethat the tabbed sections correspond with the FISS menu options. For example, theInquiry Menu, Option 14 (Healthcare Common Procedure Coding System (HCPCS)Codes) directly relates to Tab 14. To make it easier, the screens are in the sameorder as the UB-04 form. You will notice that claim entry and claim inquiry screensare identical. So that you do not become lost, it is important to keep in mind themenu option you have chosen. In addition, while working on line as you follow alongwith your manual you will see that the pages in FISS are known as Map Pages andare located in the upper left hand corner. Paying attention to the tabs and Map

Pages will ensure that you will never be lost.When entering information remember to < TAB > among the fields until you havecompleted the screen. To move on to the next screen/page, press < F8 >.Depending on the Type of Bill, the cursor will skip fields that are not required. If youpress < F3 > while you are in the middle of date entering your claim before you have‗stored‘ the claim, you will lose all the information you have keyed. If, at anytime,you press , you will be bumped totally off the system, and you must signback on.

Best wishes on your journey through FISS.

Provider Outreach and Education Team


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Table of Contents

INTRODUCTION .................................................................................................... 2 Movement Within Screens .............................................................................. 2 FISS Menu Applications .................................................................................. 3 Program Function Keys ................................................................................... 4 Standards and Conventions ............................................................................ 5

INTRODUCTION TO DIRECT DATA ENTRY (DDE) ............................................. 6 Direct Data Entry (DDE) Capabilities and Benefits .......................................... 6

Advantages of Direct Data Entry (DDE) .......................................................... 7 SIGN & SIGN OFF PROCEDURES ....................................................................... 8 DIRECT DATA ENTRY (DDE) MAIN INQUIRY MENU ........................................ 11

Beneficiary/Common Working File (CWF) Eligibility Detail Inquiry ................ 13 Diagnostic Related Grouping (DRG)/Prospective Payment System (PPS) ... 57 Claims Summary Inquiry ............................................................................... 73 Revenue Code Inquiry ................................................................................ 128 Healthcare Common Procedure Coding System (HCPCS) Inquiry ............. 132 Diagnosis and Procedure Inquiry ................................................................ 147

Adjustment Reason Codes Inquiry .............................................................. 150 Reason Code Inquiry .................................................................................. 155 Zip Code File Inquiry ................................................................................... 165 Occurrence Span Code (OSC) Repository Inquiry ...................................... 168 Claim Count Summary ................................................................................ 170 Home Health Payment Totals ..................................................................... 173

America National Standards Institute (ANSI) Reason Codes Inquiry .......... 174 Check History Inquiry .................................................................................. 179

CLAIMS AND ATTACHMENTS ENTRY ............................................................ 182 Claims Entry ................................................................................................ 183 Roster Bill Entry .......................................................................................... 206

CLAIMS CORRECTION ..................................................................................... 210 Claims Correction ........................................................................................ 212 Claim Adjustments ...................................................................................... 217 Claim Cancels ............................................................................................. 220

ATTACHMENTS ................................................................................................ 223 Therapy Attachment .................................................................................... 223

ONLINE REPORTS ............................................................................................ 244 HEALTH INSURANCE QUERY ACCESS (HIQA) .............................................. 254

APPENDIX ............................................................................................. CCLXXXIV Status/Location ..................................................................................... cclxxxiv

Adjustment Reason Codes..................................................................... cclxxxv Outpatient Code Editor (OCE) Flags .................................................... cclxxxvii Provider Notices ........................................................................................ ccxci Revisions...................................................................................................ccxcii


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Introduction

Movement Within ScreensMoving around the Fiscal Intermediary Standard System (FISS) is quite easy withthe use of the program function keys. Your keyboard may have ‗PF‘ or ‗F‘ keys.Regardless, both types of function keys will work the same.

Roll in / Roll out / Slidingo Screen Control (SC) in the upper left hand corner of a screen allows

the operator to access another area within FISS to research dataand then return to the previous screen. Press < F3> to return toprevious screen.

Screen Control (SC) o In the ‗SC‘ field enter the menu transaction number and the

transaction type. Press < F3 > to return to previous screen. Paging

When all of the data for a particular file cannot fit onto one screen, themultiple screens require for that file are known as pages. Paging allowsthe operator to move backwards and forwards, in page increments, amongthe multiple pages of a screen.

To move forward one page at a time, press < F8 >To move backward one page at a time, press < F7 >In some files it may be possible to move forward or backwardmore than one page, press the < HOME > key. The cursor willmove to the upper right hand corner of the screen to the―PAGE‖ field. Enter the number of the desired page andpress < ENTER >.

ScrollingThe scrolling function is the mechanism by which an operator is able tomove up or down within any given page.

To scroll up within a page, press < F5 >To scroll down within a page, press < F6 >

Help FunctionThe help function provides operator assistance in error resolution bydisplaying reason code information on error reasons assigned by thesystem and displayed on the screen. There are two ways to access theexplanation of a reason code on a claim/file screen.

Press < F1 > while the cursor is anywhere on the claim/file screen toreceive an explanation of the first reason code appearing on thatscreen.Press < F1 > when the cursor is under a specific reason code on theclaim/file screen to receive an explanation of that particular reasoncode.


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FISS Menu Applications

MAIN MENU01 INQUIRIES

02 CLAIMS/ATTACHMENTS03 CLAIMS CORRECTIONS04 ONLINE REPORTS VIEW

01 – INQUIRIES 02 – CLAIMS/ATTACHMENTS10 BENEFICIARY/CWF 20 INPATIENT11 DRG (PRICER/GROUPER) 22 OUTPATIENT12 CLAIMS 24 SNF13 REVENUE CODES 26 HOME HEALTH14 HCPC CODES 28 HOSPICE15 DX/PROC CODES 49 NOE/NOA16 ADJUSTMENT REASON CODES 87 ROSTER BILL ENTRY17 REASON CODES ATTACHMENT ENTRY19 ZIP CODE FILE 41 HOME HEALTH56 CLAIM COUNT SUMMARY 54 DME HISTORY68 ANSI REASON CODES 57 ESRD CMS-382 FORMFI CHECK HISTORY

03 – CLAIMS CORRECTION 03 – CLAIM CORRECTIONCLAIMS CORRECTION ATTACHMENTS

21 INPATIENT 42 PACEMAKER

23 OUTPATIENT 43 AMBULANCE25 SNF 44 THERAPY27 HOME HEALTH 45 HOME HEALTH29 HOSPICE

CLAIM ADJUSTMENT30 INPATIENT31 OUTPATIENT32 SNF33 HOME HEALTH35 HOSPICE

CLAIM CANCELS

50 INPATIENT51 OUTPATIENT52 SNF53 HOME HEALTH55 HOSPICE


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Program Function Keys

An operator can perform specific processes within the system utilizing theprogram function keys. The correct function keys for each MAP will be displayedat the bottom of the screen. The table below identifies the keys used in FISS.

PFKEY FUNCTION

PF1 Access specific reason code file information about the error received.

PF2

From claim page 3 (MAP1033), jumps the user to claim page 32(MAP103I) for the first revenue code in error; or, when placed on aspecific revenue code line on claim page 3, the system automaticallygoes to the same revenue code on MAP103I.

PF3Exits to previous menu or sub-menu. When in a roll-out screen, bringsthe customer back to the original screen.

PF4 Exits system by terminating the session.

PF5 Scroll backward within a page.

PF6 Scrolls forward within a page.

PF7 Moves back one (1) page at a time.

PF8 Moves forward one (1) page at a time.

PF9

Stores or updates data that has been entered in an entry or updatetype transaction. If used while entering data, the "PF9" key will returnerror reasons on-line.

PF10Moves left to columns 1 - 80 (within a claim record.) Also allows accessto the last page of a beneficiary history when in claim summary by HIC.

PF11 Moves right to columns 81 - 132 (within a claim record.)

PF12Deletes records from user controlled file (Operator must have authorityto utilize.)


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Standards and Conventions

KEYS DESCRIPTION

ARROWS

Use the arrow ←↑→↓ keys to move one character at a time in any directionwithin a field. See ‗TAB KEYS‘ section for information regarding moving

between fields.

TAB

Press to move forward between fields. Press + tomove backward between fields. Tabbing backwards is helpful if the cursor is atthe top of the screen and you need to move to the bottom of the screen. Some

keyboards may be equipped with a ‗back tab‘ key. If your screen ‗freezes‘ or ‗locks‘, press the key or the ke y to

reset your session.

CURSORThe cursor is the flashing underline or ‗block‘ that show you where you are on

the screen

END KEYTo field exit or ‗clear‘ field. In FISS it is important that you NOT spacebar to

clear fields. The space can be a character to FISS.


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Introduction to Direct Data Entry (DDE)The DDE system was designed as an integral part of the Fiscal IntermediaryStandard System (FISS). DDE will offer various tools to help Providers obtainanswers to many questions without contacting Medicare Part A via telephone or

written inquiry. DDE will also provide another avenue for electronically submittingclaims to the Fiscal Intermediary.

Direct Data Entry (DDE) Capabilities and BenefitsOn line access to information on the Common Working File (CWF) -Providers will be able to access eligibility data on the CWF file. This fileshows eligibility data, utilization information, deductible status, TherapyCaps, HMO enrollment/disenrollment data and Medicare Secondary Payer(MSP) data.

On line data entry of initial claims - DDE allows Providers that currentlyhave no other way to submit electronic claims, to enter initial claims.Providers will be able to enter claims directly into the Fiscal IntermediaryStandard System and receive the identical edits received by FiscalIntermediary personnel when hard copy claims are entered. This will helpensure clean, error-free submissions on claims, which may otherwise besubmitted to the Intermediary by a Provider in paper form. Providers whohave no current means of submitting electronic claims will have an avenueto do so with on line data entry.

On line resubmission of claims previously returned to provider (RTP) forbilling errors – Providers will be able to electronically submit claimspreviously returned for billing errors. Providers may continue to submitclaims using existing electronic means, e.g., system to system, tape totape, etc. Since editing of claims submitted via other electronic avenues isnot as intense as the FISS on line editing, Providers generally realize someportion of their electronically submitted claims will be returned for billingerrors. All claims returned for correction, whether they were originallysubmitted in electronic or paper form, may be resubmitted via DDE, andthe resubmitted claims will be edited with the same intensity as new claims.


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On line access to intermediary files (revenue Codes, Healthcare CommonProcedure Coding System (HCPCS) and the Reason Code Files) – Thiswill help Providers know immediately what Revenue Codes and HCPCScodes are acceptable on any given billing date. In addition, Providers will

be able to determine what specific fee schedule amounts are in effect onany given date. DDE also allows on line claim status inquiry to determine ifand when a claim was processed.

Advantages of Direct Data Entry (DDE) All Medicare Part A Providers can use DDE. Using DDE will allow the Provider toenter electronically, on line and in real time:

Key and send UB04 claims

Correct, adjust and cancel claims

Inquire about the patient‘s eligibility

Access the Revenue Code, HCPCS, ICD-9 code and Procedure Codeinquiry files

Access the Reason Code and Adjustment Reason code inquiry files

Determine DRG for Inpatient hospital claims


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Sign & Sign Off Procedures

Signing On

Accessing FISS

From the sign-on screen, the following:

1. Type your User Identification (ID)2. Tab to the PASSWORD field and type your password

For password problems, please contact the Customer Contact Center at1-877-235-8073, or follow the Provider Password Reset Instructions :

Rules for the use of the RACF ID and Password :

TS00P420 - TS00M42 Companion Data Services, LLC 09/07 09:23

Type your userid and password:

Userid ===============>Password =============>

New Password =========>Verify New Password ==>

Note: Parts of this computer system may be owned by the United States Government. If so,the Center for Medicare and Medicaid Services (CMS) maintains ownership andresponsibility for those parts. Users of this system must adhere to CMS InformationSecurity Policies, Standards and Procedures. Any usage of this system may be monitored,recorded, and audited. Any unauthorized use of this system is prohibited and subject tocriminal and civil penalties. Any use of this system constitutes consent to any and allmonitoring and recording of the user's activities.

PF 3=End

3. Press < ENTER >, the SIGN-ON IS COMPLETE screen will appear.

https://www.novitas-solutions.com/parta/fiss/password.htmlhttps://www.novitas-solutions.com/parta/fiss/password.htmlhttps://www.novitas-solutions.com/parta/fiss/password.htmlhttps://www.novitas-solutions.com/parta/fiss/rules.htmlhttps://www.novitas-solutions.com/parta/fiss/rules.htmlhttps://www.novitas-solutions.com/parta/fiss/rules.htmlhttps://www.novitas-solutions.com/parta/fiss/rules.htmlhttps://www.novitas-solutions.com/parta/fiss/password.html


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SIGN-ON IS COMPLETE

4. Type “FSS0” at the cursor.

5. Press < ENTER >. The FISS MAIN MENU will appear.

MAP1701 NOVITAS SOLUTIONS ACMMA871 06/11/09 ABC0000 MAIN MENU C20092ZF 13:12:03

01 INQUIRIES

02 CLAIMS/ATTACHMENTS

03 CLAIMS CORRECTION

04 ONLINE REPORTS

ENTER MENU SELECTION:

PLEASE ENTER DATA - OR PRESS PF3 TO EXIT


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Signing Off

Instructions

1. Press < F4 > from any screen. The message Session SuccessfullyTerminated will appear.

SESSION SUCCESSFULLY TERMINATED

2. Type CESF (space) LOGOFF at the cursor.

3. Press < ENTER >.

Note : You will be typing over the Session Successfully Terminated message.


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Direct Data Entry (DDE) Main Inquiry Menu

PurposeThe Inquiry Menu allows Providers to research certain system files in an inquirymode. There are twelve (12) inquiry sub-menus available to the Provider.

Accessing the Inquiry Menu

1. From the MAIN MENU (MAP 1701) type 01 . Press < ENTER>

MAP1702 NOVITAS MEDICARE SERVICES ACMMA871 06/11/09 ABC000 INQUIRY MENU C20092ZF 13:22:01

01 INQUIRES02 CLAIMS/ATTACHMENTS

03 CLAIMS CORRECTION04 ONLINE REPORT VIEW

ENTER MENU SELECTION: 01

PLEASE ENTER DATA OR PRESS PF3 TO EXIT

1. Press < ENTER >, the INQUIRY MENU will appear.

MAP1702 NOVITAS SOLUTIONS ACMMA871 06/11/09

ABC0000 INQUIRY MENU C20092ZF

BENEFICIARY/CWF 10 ZIP CODE FILE 19

DRG (PRICER/GROUPER) 11 OSC REPOSITORY INQUIRY 1A

CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56

REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67

HCPC CODES 14 ANSI REASON CODES 68

DX/PROC CODES 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16

REASON CODES 17

ENTER MENU SELECTION:PLEASE ENTER DATA – OR PRESS PF3 TO EXIT


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There are twelve (12) inquiry options, which allow you to:o Verify beneficiary eligibilityo Check claim statuso View a summary report of claims currently processingo Verify revenue codes, diagnosis codes, HCPCS (Healthcare

Common Procedure Coding System), adjustment reason codes,reason codes, and ANSI (American National StandardsInstitute) codes

o View DRG (Diagnosis Related Groups) Pricer/Grouperinformation

o View the amounts and payment dates of the last three checks orelectronic funds transfers (EFT)


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Beneficiary/Common Working File (CWF) Eligibility Detail Inquiry

PurposeThe purpose of the beneficiary screens is to provide access to all beneficiariescontained on the eligibility file. The operator will use this file to verify the beneficiaryeligibility data.

Screens 1 and 2 display beneficiary information stored in FISS. Screens 3 andbeyond, display beneficiary information based in the Common Working File (CWF).The CWF/HIQA file contains the most complete beneficiary information.

Note: The provider must have the Health Insurance Claim (HIC) number, last name,first initial, sex, and the birth date to access the beneficiary file information.

Access:From the Inquiry Menu, to access the Beneficiary/CWF sub-menu:In the Enter Menu Selection field, Type 10, Press < ENTER >

MAP1702 NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 INQUIRY MENU C20092ZF 13:22:01

BENEFICIARY/CWF 10 ZIP CODE FILE 19


CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67


DX/PROC CODES 15 CHECK HISTORY FI

ADJUSTMENT REASON CODES 16

REASON CODES 17

ENTER MENU SELECTION: 10PLEASE ENTER DATA - OR PRESS PF3 TO EXIT


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Option 10 – Beneficiary/Common Working File (CWF) InformationThe eligibility detail inquiry screens display current Medicare Part A and Part Bentitlement information about a specific beneficiary. There are four (4) pages ofeligibility information and additional pages of information, if applicable.

To start the inquiry process to verify eligibility/utilization for a specific beneficiary,enter the following information as it appears on the Medicare card:

Health Insurance Claim (HCI) NumberLast Name and First InitialGender / Sex8 digit date of birth in MMDDYYYY format

Use the < TAB > key to move among the fields. Do not press until allfields are completed.

Once you press < ENTER >, the system will search for the beneficiary information. Ifa match is found, the remaining fields will be populated. If the beneficiary recorddoes not exist on the file, the message ―Error has occurred in FSS01750AT:STATUS IS: NOT FOUND‖ appears at the bottom of the screen. If error occurs,verify the beneficiary information and repeat the process.

MAP1751 NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ELIGIBILITY DETAIL INQUIRY C20092ZF 13:39:42

HIC CURR XREF HIC PREV XREF HICTRANSFER HIC C-IND LTR DAYSLN FN MI SEX

DOB DOD ADDRESS: 1 23 45 6

ZIP:

CURRENT ENTITLEMENTPART A EFF DT TERM DT PART B EFF DT TERM DT

CURRENT BENEFIT PERIOD DATAFRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYSSNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS

PSYCHIATRICPSY 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


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There are two (2) pages of FISS eligibility, two (2) pages of Common Working File(CWF) eligibility and additional demographic information.

MAP1751 NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ELIGIBILITY DETAIL INQUIRY C20092ZF 13:39:42

HHIICC 111111111A CURR XREF HIC PREV XREF HICTRANSFER HIC C-IND LTR DAYSLN DOE FN JOHN MI SEX M DOB 01011900 DOD

ADDRESS: 1 23 45 6

ZIP:

CURRENT ENTITLEMENTPART A EFF DT TERM DT PART B EFF DT TERM DT

CURRENT BENEFIT PERIOD DATAFRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYSSNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS

PSYCHIATRICPSY 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

Eligibility Detail Inquiry Screen 1 (MAP 1751)

Note: MAP numbers reference FISS screens. MAP numbers are listed in the upperleft corner of the screen, and page numbers are listed in the upper right corner of thescreen.

ex. ACMMA8971 Region

ex. 06/11/09 Date

ex. ABC0000 User ID

ex. C20092ZF Release

ex. 13:47:32 Time

SC: Allows user to jump from one system application toanother. Key the two-digit application number and press


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Beneficiary Information

HIC Health Insurance Claim (HIC) number as it appears onthe Medicare ID card.

CURR XREF HIC Current Cross Reference Health Insurance Claim - If theHealth Insurance Claim number has changed for thebeneficiary, this field represents the most recent number.

PREV XREF HIC This field is not used.

TRANSFER HIC This field is not used.

C-IND Century Indicator - This field represents a one-positioncode identifying if the beneficiary‘s date of birth is in the

19th

or

20th

century. The valid values are: 8 = 1800‘s 9 = 1900‘s

LTR DAYS Life Time Reserve Days – Lifetime reserve daysremaining.

LN Last Name – Patient‘s last name as it appears on theMedicare Identification (ID) Card.

FN First Name – Patient‘s last name as it appears on theMedicare ID Card.

MI Middle Initial - Patient‘s middle initial.

SEX Patient‘s gender/sex. The valid values are:F FemaleM Male

DOB Date of Birth - Date of birth of the beneficiary inMMDDCCYY format.

DOD Date of Death - Date of death of the beneficiary inMMDDYY format.

ADDR Address - Beneficiary's street address including thehouse number, post office box number, and/or apartmentnumber, address, state address abbreviation.


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ZIP ZIP Code - Patient's ZIP code. This is a nine positionalphanumeric field.

CURRENT ENTITLEMENTPART A EFF DT Part A Current Entitlement Date - Current Part A

entitlement date. The format is MMDDYY.

TERM DT Part A Prior Termination Date - Termination date of theprior Part A entitlement. The format is MMDDYY.

PART B EFF DT Part B Current Entitlement Date - Current Part Bentitlement date. The format is MMDDYY.

TERM DT Part B Prior Termination Date - Termination date of theprior Part B entitlement. The format is MMDDYY.

CURRENT BENEFIT PERIOD DATA

FRST BILL DT First Bill Date - The date of the earliest billing for thebenefit period. The format is MMDDYY.

LST BILL DT Last Bill Date - The date of the latest billing for the benefitperiod. The format is MMDDYY.

HSP FULL DAYS Hospital Full Days - Number of regular hospital full daysthe beneficiary has remaining .

HSP PART DAYS Hospital Coinsurance Days - The number of hospitalcoinsurance days remaining .

SNF FULL-DYS Skilled Nursing Facility Full Days - The number of SNFfull days the beneficiary has remaining .

SNF PART DYS Skilled Nursing Facility Coinsurance Days - The numberof SNF coinsurance days the beneficiary has remaining.

INP DED REMAIN Inpatient Deductible Remaining - The amount ofinpatient deductible remaining to be met by thebeneficiary for the current benefit period.


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BLD DED PNTS Blood Deductible Pints - The number of blood deductiblepints remaining to be met by the beneficiary.

PSYCHIATRIC PSY DAYS REMAIN Psychiatric Days Remaining - This field identifies the

number of lifetime psychiatric days the beneficiary hasremaining .

PRE PHY DYS USED Pre-Entitlement Psychiatric Days Used - The number ofpre-entitlement psychiatric days the beneficiary has used.

PSY DIS DT Psychiatric Discharge Date - Last discharge date from apsychiatric hospital for this beneficiary. The format is

MMDDYY.INTRM DT IND Interim Date Indicator - An interim date for psychiatric

services. The valid values are:Y Date is through date of interim bill - utilization dayN Discharge date - not a utilization day

Note : A utilization day is a day that is deducted from the beneficiary‘s benefitperiod.


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1. From the Eligibility Detail Inquiry Screen 1 (MAP 1751), press < F8 > to display

Screen 2 (MAP 1752).MAP1752 NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ELIGIBILITY DETAIL INQUIRY C20092ZF 13:39:42

RI MAMMO DTPART B DATA

SRV YR MEDICAL EXPENSE BLD DED REM PSY EXPSRV YR BLD DED CSH DED

PLAN DATA

ID CD OPT CD EFF DT CANC DTID CD OPT CD EFF DT CANC DTID CD OPT CD EFF DT CANC DT

HOSPICE DATAPERIOD 1ST DT PROVIDER INTER

OWNER CHANGE ST DT PROVIDER INTER2ND ST DT PROVIDER INTER TERM DTOWNER CHANGE ST DT PROVIDER INTER

1ST BILL D LST BILL DT DAYS BILLED

PROCESS COMPLETED ---- PLEASE CONTINUEPRESS PF3-EXIT PF7-PREV PAGE PF8-CWF INQUIRY

Field Descriptions for Eligibility Detail Inquiry Screen 2 (MAP 1752)



ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


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PLAN DATA

ID CD Plan Identification Code - The Plan identification code isan alphanumeric code identifying a specific Plan. This

field occurs three times. The structure of the identificationnumber is as follows:Position 1 = HPosition 2&3 = State codePosition 4&5 = Plan number within the state

OPT CD Plan Option Code - Whether the services are restricted orunrestricted. This field occurs three times. The validvalues are:

Unrestricted

1 Intermediary to process all Part A and B providerclaims.2 Plan to process claims for directly provided

services and for services from providers witheffective arrangements.

Restricted A Intermediary to process all Part A and B provider

claims.B Plan to process claims only for directly provided

services.C Plan to process all claims.

EFF DT Plan Effective Date - The effective date of a beneficiary'sPlan entitlement. The format is MMDDYY, with threeoccurrences.

CANC DT Plan Cancel Date - The ending date of a beneficiary'sPlan. The format is MMDDYY, with three occurrences.


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HOSPICE DATA

These fields maintain the history of a beneficiary's first two selections of Hospice.

PERIOD Hospice Period - The specific Hospice Election Period.The valid values are:1 The first time a beneficiary uses Hospice benefits.2 The second time a beneficiary uses hospice benefits.

1ST DATE First Start Date - The start date of the beneficiary's periodwith the Hospice provider. The format is MMDDYY.

PROVIDER Provider Number - The identification number assigned byMedicare to the Hospice provider.

INTER Intermediary Number - The intermediary number for theHospice provider.

TERM DT Termination Date - The ending date of a beneficiary'selection period. The format is MMDDYY.

OWNER CHANGE ST Change of Ownership Start Date - The new owner of theHospice provider if a change of ownership occurs withinan election period. The format is MMDDYY.

2ND ST DT Second Start Date - The start date of the beneficiary'ssecond period with the Hospice provider. The format isMMDDYY.

DAYS BILLED Days Billed - The number of hospice days billed to datefor a particular beneficiary.


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Eligibility Detail Inquiry Screen 3 (MAP 175J)

2. From the Eligibility Detail Inquiry Screen 2 (MAP 1751), press < F8 > to displayEligibility Screen 3 (MAP175J)

MAP175J NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ACCEPTED C20092ZF 13:39:42 HIC NM IT DB SXPRVN SERVC TECH D PROF D ¦ PRVN SERVC TECH D PROF D ¦ PRVN SERVC TECH D PROFDCARD/80061 DIAB/82951 PAPT/G0147CARD/82465 PCBE/G0101 PAPT/G0148CARD/83718 PPV /90732 AAA /G0389CARD/84478 PPV /90669 PTWR/G9143COLO/G0104 PROS/G0102 IPPE/G0402COLO/G0105 PROS/G0103 IPPE/G0403COLO/G0106 PAPT/Q0091 IPPE/G0404COLO/G0120 GLAU/G0117 IPPE/G0405COLO/G0121 GLAU/G0118 PULM/G0424FOBT/G0107 MAMM/G0202 CR /FOBT/G0328 MAMM/G0203 ICR /FOBT/82270 MAMM/76092 AWV/G0438

IPPE/G0344 MAMM/77057 AWV/G0439IPPE/G0366 PAPT/P3000 PPV/90670IPPE/G0367 PAPT/G0123 TELEHIPPE/G0368 PAPT/G0143DIAB/82947 PAPT/G0144 GDR GDRDIAB/82950 PAPT/G0145 GDR GDR

Processed Completed – Please ContinuePress PF3 – Exit PF7 – Prev Page PF8 – Next Page

Field Descriptions for Eligibility Detail Inquiry Screen 3 (MAP 175J)


ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


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HIC Beneficiary Health Insurance Claim (HIC) number

NM Beneficiary last name

IT Beneficiary first initialDB Beneficiary date of birth

SX Beneficiary sex

PREVENTIVESERVICES CARDIOVASC – Cardiovascular

COLORECTAL - ColorectalFOB TEST – Fecal Occult Blood TestIPP EXAM – Initial Preventive Physical Examination

PCB EXAM – Pelvic and Clinical Breast ExaminationPPV – Pneumococcal Pneumonia VaccinePROSTATE - ProstateDIABETES – DiabetesGLAU – GlaucomaMAMM – MammographyPAP TEST - Pap Smear TestPAPT – Pap Smear Test

AAA – Abdominal Aortic AneurysmPTWR – Pharmacogenomic Testing Warfarin ResponseIPPE – Preventive Physical ExaminationPULM – Pulmonary RehabilitationCR – Cardiac RehabilitationICR – Intensive Cardiac Rehabilitation

AWV – Annual Wellness VisitPPVTELEH – Telehealth Services

All Preventive Services on the screen have theirassociated Healthcare Common Procedure CodingSystem (HCPCS) listed next to the service.

TECH DATE Next Eligible Technical Date for the Preventive Service(MMDDCCYY)


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PROF DATE Next Eligible Professional Date for the Preventive Service(MMDDCCYY)

NOTE: Both TECH DATE and PROF DATE may have

some abbreviated date messages that relate to: AGE – Beneficiary not eligible due to AgeGDR – Beneficiary not eligible due to Gender000 – Service not applicableSRV – Beneficiary not eligible for the ServiceVAC – Beneficiary already VaccinatedRCVD – Beneficiary already received the ServiceDOD – Beneficiary not eligible due to Date of Death


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3. From the Eligibility Detail Inquiry Screen 3 (MAP 175J), press < F8 > to display theEligibility Detail Inquiry Screen 4 (MAP 1755).

MAP1755 NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ACCEPTED C20092ZF 13:39:42

CLAIM NAME D.O.B. SEX INTERPROV APP DT REASON CD DATE/TIME REQ IDDISP CD TYPE CENT D.O.B D.O.D

A:CURR-ENT DT TERM DT PRI-ENT DT TERM-DTB:CURR-ENT DT TERM DT PRI-ENT DT TERM-DT

LIFE: RSRV PYSCH

CURRENT BENEFIT PERIOD DATAFRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYSSNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTSPRIOR BENEFIT PERIOD DATAFRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYSSNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS

CURR B: YR CASH BLOOD PSYCH PT OTPRIR B: YR CASH BLOOD PSYCH PT OT

PROCESS COMPLETED --- PLEASE CONTINUEPRESS PF3-EXIT PF7-PREV PAGE PF8-NEXT PAGE

Field Descriptions for Eligibility Detail Inquiry Screen 4 (MAP 1755)Note: MAP numbers reference FISS screens. MAP numbers are listed in the upperleft corner of the screen, and page numbers are listed in the upper right corner of thescreen.


ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


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SC Allows user to jump from one system application toanother. Key the two-digit application number and press.

CLAIM Health Insurance Claim Number - This field identifies thehealth insurance claim number assigned to thebeneficiary by CMS.

NAME Name - This field identifies the first and last name of thebeneficiary.

D.O.B. Date of Birth - This field identifies the date of birth of thebeneficiary/patient. This is a six-digit field in MMDDYYformat.

SEX Sex - This field identifies the sex of the beneficiary. Thevalid values are:F FemaleM Male

INTER Intermediary Number - This field identifies theintermediary number for the provider.

PROV Provider Number - This field displays the identificationnumber of the provider. It is system generated forexternal operators that are directly associated with oneprovider.

APP DT Applicable Date - This field is used for spelldetermination, i.e., admission date. The format isMMDDYY.

REASON CD Reason Code - This field identifies the reason for theinquiry. The valid values are:1 Status inquiry2 Inquiry related to an admission

DATE/TIME Date (Julian) and Time Stamp of the inquiry transaction.The format is YYDDDHHMMSS.


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REQ ID Requester ID - This field identifies the individual whosubmitted the inquiry.

DISP CD Disposition Code - This field identifies a code assigned

when the request is processed through the CWF hostsite. The valid values are:01 Part A inquiry approved; beneficiary has never

used Part A services.02 Part A inquiry approved; beneficiary has had some

prior utilization.03 Part A inquiry rejected.04 Qualified approval; may require further

investigation.05 Qualified approval; according to CMS‘s records,

this inquiry begins a new benefit period.

TYPE Type of Reply - This field identifies the type of CWFreply. The valid value is:3 Accept

CENT D.O.B. Century Code for Date of Birth - This field identifies thecentury of the beneficiary/patient's date of birth. The validvalues are:8 18th Century9 19th Century

DOD Date of Death - This field identifies the date of death ofthe beneficiary.

A:CURR-ENT DT Part A Current Entitlement Date - This field identifies thecurrent Part A entitlement date. The format is MMDDYY.

TERM DT Part A Termination Date - This field identifies thetermination date of the current entitlement. The format isMMDDYY.


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PRI-ENT DT Part A Prior Entitlement Date - This field identifies theprior Part A entitlement. The format is MMDDYY.

TERM DT Part A Prior Termination Date - This field identifies the

termination date of the prior Part A entitlement. Theformat is MMDDYY.

B:CURR-ENT DT Part B Current Entitlement Date - This field identifies thecurrent Part B entitlement date. The format is MMDDYY.

TERM DT Part B Termination Date - This field identifies thetermination date of the current entitlement. The format isMMDDYY.

PRI-ENT DT Part B Prior Entitlement Date - This field identifies the

prior Part B entitlement date. The format is MMDDYY.TERM DT Part B Prior Termination Date - This field identifies the

termination date of the prior Part B entitlement. Theformat is MMDDYY.

LIFE: RSRV Lifetime Reserve Days - This field identifies the numberof lifetime reserve days remaining for the beneficiary.

PYSCH Psychiatric Days Remaining - This field identifies thenumber of lifetime psychiatric days remaining for thebeneficiary.

CURRENT BENEFIT PERIOD DATA

FRST BILL DT First Bill Date - This field identifies the date of the earliestbilling action in the current benefit period. The format isMMDDYY.

LST BILL DT Last Bill Date - This field identifies the date of the latestbilling action in the current benefit period. The format isMMDDYY.


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HSP FULL DAYS Hospital Full Days - This field identifies the number ofregular hospital full days the beneficiary has remainingin the current benefit period.

HSP PART DAYS Hospital Coinsurance Days - This field identifies thenumber of hospital coinsurance days the beneficiary hasremaining in the current benefit period.

SNF FULL DAYS Skilled Nursing Facility Full Days - This field identifies thenumber of SNF full days the beneficiary has remaining in the current benefit period.

SNF PART DAYS Skilled Nursing Facility Coinsurance Days - This fieldidentifies the number of SNF coinsurance days thebeneficiary has remaining i n the current period.

INP DED REMAIN Inpatient Deductible Amount Remaining - This fieldidentifies the amount of inpatient deductible amountremaining to be met by the beneficiary for the benefitperiod.

BLD DED PNTS Blood Deductible Pints - This field identifies the numberof blood deductible pints remaining to be met by thebeneficiary for the benefit period.

PRIOR BENEFIT PERIOD DATA

FRST BILL DT First Bill Date - This field identifies the date of the earliestbilling action in the prior benefit period. The format isMMDDYY.

LST BILL DT Last Bill Date - This field identifies the date of the latestbilling action in the prior benefit period. The format isMMDDYY.

HSP FULL DAYS Hospital Full Days - This field identifies the number ofregular hospital full days the beneficiary has remaining in the prior benefit period.


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HSP PART DAYS Hospital Part Days - This field identifies the number ofhospital coinsurance days the beneficiary has remaining in the prior benefit period.

SNF FULL DAYS Skilled Nursing Facility Full Days - This field identifies thenumber of SNF full days the beneficiary has remaining in the prior benefit period. This is a two-digit field.

SNF PART DAYS Skilled Nursing Facility Part Days - This field identifiesthe number of SNF coinsurance days the beneficiary hasremaining in the prior period.

INP DED REMAIN Inpatient Deductible Amount Remaining - This fieldidentifies the amount of inpatient deductible amountremaining to be met by the beneficiary for the benefit

period.BLD DED PNTS Blood Deductible Pints - This field identifies the number

of blood deductible pints remaining to be met by thebeneficiary/patient for the benefit period.

CURR B: YR Most Recent Part B Year - This field identifies the mostrecent Medicare Part B benefit year. The format is YY.

CASH Medicare Part B Cash Deductible Remaining to be Met -This field identifies the amount of cash deductibleremaining to be met for the most recent Part B year.

BLOOD Medicare Part B Blood Deductible Remaining to be Met - This field identifies the amount of blood deductible pintsremaining to be met for the most recent Part B year.

PSYCH Medicare Part B Psychiatric Limit Remaining - This fieldidentifies the Part B psychiatric limit remaining for thebenefit year.


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PT Part B Physical Therapy Limit Remaining - This fieldidentifies the Part B physical therapy limit remaining forthe most recent Medicare Part B benefit year.

OT Part B Occupational Therapy Limit Remaining - Thisfield identifies the Part B occupational therapy limitremaining for the most recent Medicare Part B benefityear.

PRIR B: YR Prior Part B Year - This field identifies the prior MedicarePart B benefit year. The format is YY.

CASH Part B Cash Deductible Remaining to be Met - This fieldidentifies the amount of cash deductible remaining to bemet for the prior Part B benefit year.

BLOOD Part B Blood Deductible Remaining to be Met - Thisfield identifies the amount of blood deductible remainingto be met for the prior Part B benefit year.

PSYCH Part B Psychiatric Limit Remaining - This field identifiesthe Part B psychiatric limit remaining for the prior Part Bbenefit year. This field is currently not used.

PT Part B Physical Therapy Limit Remaining - This fieldidentifies the Part B physical therapy limit remaining forthe prior Part B benefit year.

OT Part B Occupational Therapy Limit Remaining - Thisfield identifies the Part B occupational therapy limitremaining for the prior Part B benefit year.


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4. From the Eligibility Detail Inquiry Screen 4 (MAP 1755), press < F8 > to display theEligibility Detail Inquiry Screen 5 (MAP 1756).


DATA IND NAME ZIP

Plan: ENR CDPlan CURR: ID CD OPT CD ENT DT TERM DTPlan PRIR: ID CD OPT CD ENT DT TERM DT

OTHER ENTITLEMENTS OCCURRENCE CD/DATE /

ESRD CD/DATE /

CAT DATA: PSYCH DISCHG IND DAYS USED BLOOD

YR APP MET BLD CO FL FRM TOIND INT ADM FRM TO APP

ADJ IND CALC DED CMS DTYR APP MET BLD CO FL FRM TOIND INT ADM FRM TO APP

ADJ IND CALC DED CMS DT





ex. 06/11/09 Date

ex. ABC0000 User ID



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ex. 13:47:32 Time

SC Allows user to jump from one system application toanother. Key the two-digit application number and press

.DATA IND Data Indicators - This is a 10-digit field. The valid values

for each position are:

Position 1: Part B Buy In0 Does not apply1 State buy-in involved

Position 2: Alien Indicator0 Does not apply

1 Alien non-payment, provision may applyPosition 3: Psychiatric Pre-Entitlement0 Does not apply1 Psychiatric pre-entitlement reduction applied

Position 4: Reason For Entitlement0 Normal entitlement1 Disability2 End stage renal disease (ESRD)3 Has or had ESRD, but current DIB4 Old age but has or had ESRD8 Has or had ESRD and is covered under Part A

premium9 Covered under Part A premium

Position 5: Part A Buy-In0 No Part A buy-in1 Part A buy-in appliesPosition 6: Rep Payee Indicator0 Does not apply1 Selected for GEP contract2 Has Rep Payee3 Both conditions apply

Positions 7-10: Not Used at This Time (pre-filled withzeroes)


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NAME Name - This field identifies the full name of thebeneficiary in last name, first name, middle initial format.

ZIP ZIP Code - This field identifies the ZIP code of residence

of the beneficiary/patient. This field has two sub-fields forthe first 5 positions of the ZIP code and for the second 4positions of the ZIP code.

Plan: ENR CD Plan Enrollment Code - This field identifies the number ofperiods of enrollment. The valid values are: '0', '1', '2',and '3' indicating '0', '1', '2', or more than two periods ofenrollment.

Plan CURR: ID CD Plan Current Identification Code - This field identifies thecurrent Plan. The format is as follows:

Position 1 'H' or '1' - '9'Positions 2 & 3 State codePositions 4 & 5 Plan number within the state

OPT CD Plan Option Code - This field identifies whether thecurrent Plan services are restricted or unrestricted. Thevalid values are:

Unrestricted1 Intermediary to process all Part A and Part B

provider claims.2 Plan to process claims for directly provided

services and for services from providers witheffective arrangements, intermediary to process allother claims.

Restricted A Intermediary to process all Part A and Part B

provider claims.B Plan to process all claims only for directly provided



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ENT DT Plan Entitlement Date - This field identifies the effectivedate of the beneficiary‘s current Plan/HMO entitlement.The format is MMDDYY, and may contain zeros.

TERM DT Plan Termination Date - This field identifies thetermination date of the beneficiary's current Plan/HMOenrollment. The format is MMDDYY, and may containzeros.

Plan PRIR: ID CD Prior Plan Identification Code - This field identifies theprior Plan . The valid values are:Position 1 'H' or '1' - '9'Positions 2 & 3 State codePositions 4 & 5 Plan number within the state

OPT CD Plan Option Code - This field identifies whether the priorPlan services are restricted or unrestricted. The validvalues are:

Unrestricted1 Intermediary to process all Part A and Part B

provider claims.2 Plan to process claims for directly provided

services and for services from providers witheffective arrangements, intermediary to process allother claims.

Restricted A Intermediary to process all Part A and Part B

provider claims.B Plan to process all claims only for directly provided



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The date is a six-digit field in MMDDYY formats, withvarious definitions according to the occurrence codes asfollows:1 or 2 The effective date of applicable program

involvement. A - I The date of the previous claim whereMedicare was determined to be secondary

CAT DATA: (CATASTROPHIC DATA)

This data is not currently utilized.


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HH-REC CN NM IT DB SX

PAP RSK PAP DATETECHCOM PROCOM

MAMMO RSK MAMMO DATES 0000 0000 HCPC CD 0000 DT 1 0000000 TECH CD DT 2

0000 RISK CD DT 3 00000000

TRANSPLANT INFO: COV IND TRAN IND DIS DATE

EPISODE EPISODE DOEBA DOLBASTART END





ex. 06/11/09 Date

ex. ABC0000 User ID

ex. C20092ZF Releaseex. 13:47:32 Time



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HH-REC Home Health Record - This field identifies the requestedHome Health record.

CN Document Control Number - This field displays theidentification number for a claim.

NM Last Name - This field identifies the last name of thebeneficiary.

IT First Initial - This field identifies the first initial of thebeneficiary name.

DB Date of Birth - This field identifies the date of birth of thebeneficiary/patient. The format is MMDDYYYY.

SX Sex - This field identifies the sex of thebeneficiary/patient. The valid values are:F FemaleM Male

PAP RSK Pap Smear Risk Indicator - This field identifies whether ornot the beneficiary is at risk. The valid values are:Y YesN No

PAP DATE Pap Smear Date - This field identifies the date of the lastpap smear. The format is MMDDYY.

MAMMO RSK Mammography Risk Indicator - This field identifieswhether or not the beneficiary is at risk. The valid valuesare:Y YesN No


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MAMMO DATES Mammography Dates - This is the heading for the datesprovided under the two column headings at right(TECHCOM and PROCOM). These dates are furtherdescribed below.

HCPC CD DT 1 Health Care Procedure Coding Code and Date related tomammography

TECH CD DT 2 Tech Code and Date related to mammography

RISK CD DT 3 Risk Code and Date related to mammography

TECH COM Technical Component Date - This field identifies the dateof mammography screening interpreted by a technician.The format is MMYY. Up to three technical component

dates may be displayed.PRO COM Professional Component Date - This field identifies the

date of mammography screening requiring interpretationby a physician. The format is MMYY. Up to threeprofessional component dates may be displayed.

TRANSPLANT INFO

COV IND Transplant Covered Indicator - This field identifieswhether or not the transplant was a covered procedure.Up to three coverage indicators may be displayed. Thevalid values are:N Non-covered transplant.Y Covered transplant.

TRAN IND Transplant Indicator - This field identifies the type oftransplant performed. Up to three transplant indicatorsmay be displayed. The valid values are:1 Allogeneous bone marrow2 Autologous bone marrowH Heart transplantK Kidney transplantL Liver transplant


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DIS DATE Transplant Discharge Date - This field identifies the dateof discharge for the beneficiary/patient for the transplantprocedure. The format is MMDDYY, with threeoccurrences.

HOME HEALTH INFO

EPISODE START Episode Start Date - This field identifies the start date ofa home health episode. The format is MMDDYYYY.

EPISODE END Episode End Date - This field identifies the end date of ahome health episode. The format is MMDDYYYY.

DOEBA Date Of Earliest Billing Date - This field identifies the firstservice date of the Home Health Prospective Payment

System (HHPPS) period. The format is MMDDYYYY.DOLBA Date Of Last Billing Date- This field identifies the last

service date of the HHPPS period. The format isMMDDYYYY.


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HOSPICE INFO FOR PERIODS 1 AND 2:

PERIOD 1ST ST DATE PROV INTEROWNER CHANGE ST DATE PROV INTER2ND ST DATE PROV INTER TERM DATEOWNER CHANGE ST DATE PROV INTER

1ST BILLED DATE LAST BILLED DATEDAYS BILLED REVO IND

PERIOD 1ST ST DATE PROV INTEROWNER CHANGE ST DATE PROV INTER2ND START DATE PROV INTER TERM DATEOWNER CHANGE ST DATE PROV INTER1ST BILLED DATE LAST BILLED DATEDAYS BILLED REVO IND

PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PAGE




ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


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HOSPICE INFO FOR PERIODS 1 AND 2PERIOD Hospice Period - This field identifies the specific Hospice

Election Period. The valid values are:1 The first time a beneficiary uses hospice benefits.2 The second time a beneficiary uses hospice

benefits.

1ST START DATE First Start Date - This field identifies the start date of thebeneficiary's effective period with the Hospice provider.The format is MMDDYY.

PROVIDER Provider Number - This field displays the identificationnumber assigned by Medicare to the Hospice provider.

INTER Intermediary Number - This field identifies theintermediary number of the Hospice provider.

TERM Termination Date - This field identifies the ending date ofa beneficiary's election period. The format is MMDDYY.

OWNER CHNG ST DT Change of Ownership Start Date - This field identifies thenew owner of the Hospice provider if a change ofownership occurs within an election period. The format isMMDDYY.

1ST START DATE Second Start Date - This field identifies the start date ofthe beneficiary's second effective period with the Hospiceprovider. The format is MMDDYY.


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Eligibility Detail Inquiry Screen 8 (MAP 175C)

7. From the Eligibility Detail Inquiry Screen 7 (MAP 1757), press < F8 > to displaythe Eligibility Detail Inquiry Screen 8 (MAP 175C).

MAP175C NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC ACCEPTED C20092ZF 13:39:42

HOSPICE INFO FOR PERIODS 3 AND 4:

PERIOD 1ST ST DATE PROV INTEROWNER CHANGE ST DATE PROV INTER2ND ST DATE PROV INTER TERM DATEOWNER CHANGE ST DATE PROV INTER

1ST BILLED DATE LAST BILLED DATEDAYS BILLED REVO IND

PERIOD 1ST ST DATE PROV INTEROWNER CHANGE ST DATE PROV INTER2ND ST DATE PROV INTER TERM DATEOWNER CHANGE ST DATE PROV INTER1ST BILLED DATE LAST BILLED DATEDAYS BILLED REVO IND


Field Descriptions for Eligibility Detail Inquiry Screen 8 (MAP 175C)



ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time

SC Allows user to jump from one system application (optionslisted on page 1) to another. Key the two-digit applicationnumber and press < ENTER >.


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HOSPICE INFO FOR PERIODS 3 AND 4

PERIOD Hospice Period - This field identifies the specific HospiceElection Period. The valid values are:

1 The first time a beneficiary uses hospice benefits.2 The second time a beneficiary uses hospicebenefits.

1ST START DATE First Start Date - This field identifies the start date of thebeneficiary's effective period with the Hospice provider.The format is MMDDYY.

PROVIDER Provider Number - This field displays the identificationnumber assigned by Medicare to the Hospice provider.

INTER Intermediary Number - This field identifies theintermediary number of the Hospice provider.

TERM Termination Date - This field identifies the ending date ofa beneficiary's election period. The format is MMDDYY.

OWNER CHNG ST DT Change of Ownership Start Date - This field identifies thenew owner of the Hospice provider if a change ofownership occurs within an election period. The format isMMDDYY.

1ST START DATE Second Start Date - This field identifies the start date ofthe beneficiary's second effective period with the Hospiceprovider. The format is MMDDYY.


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DAYS BILLED Days Billed - This field identifies the number of hospicedays billed to date for a particular beneficiary.

REVO IND * Revocation Indicator - This field identifies the revocation

indicator. This is a one position alphanumeric field. Thevalid values are:0 – Not revoked1 – Revoked by notice of revocation2 – Revoked by notice of revocation with a non-paymentcode of 'N' and an occurrence code '42'3 – Revoked by a hospice claim with occurrence code‗23‘.

* Note : This field is updated by the hospice billing the last claim.


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Eligibility Detail Inquiry Screen 9 (MAP 175K)

8. From the Eligibility Detail Inquiry Screen 8 (MAP 175C), press < F8 > to displaythe Eligibility Detail Inquiry Screen 9 (MAP175K)

MAP175K NOVITAS SOLUTIONS ACMMA871 06/11/09ABC0000 SC C20092ZF 13:39:42

SMOKING AND TOBACCO USE CESSATION COUNSELING SERVICES DAYS BILLED

HICN LN FI DOB SEXCOUNSELING PERIOD: 1 2 3 4 5

TOTAL SESSIONS: 0 0 0 0 0HCPCS FROM THRU PER QT TP HCPCS FROM THRU PER QT TP


Field Descriptions for MAP175K



ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


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SC Allows user to jump from one system application (optionslisted on page 1) to another. Key the two-digit applicationnumber and press .

HICN Health Insurance Claim NumberLN Last Name – This field identifies the last name of the

beneficiary/patient. This is a six-position alphanumericfield.

FI First Initial – This field identifies the first initial of thebeneficiary/patient name. This is a one-positionalphanumeric field.

DOB Date of Birth – This field identifies the date of birth of the

beneficiary/patient. This is an eight-position alphanumericfield in MMDDYYYY format.

SEX Sex – This field identifies the sex of thebeneficiary/patient. This is a one-position alphanumericfield. The valid values are:'F' Female'M' Male

COUNSELINGPERIOD Counseling Period – This field identifies up to five years

of counseling data. This is a one-position alphanumericfield. The valid values are:'1' One year'2' Two years'3' Three years'4' Four years'5' Five years

TOTAL SESSIONS Total Sessions – This field identifies the number ofsessions billed for each beneficiary. This is a one-position alphanumeric field.

NOTE: If a date range is billed on a detail, and a quantity that matches the range is notidentified, CWF posts the session as 1 unit. (i.e., 10/25 - 10/27 Unit 1 will post as 1 session).


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The following fields display up to 28 occurrences of the maximum sessionoccurrences from the most recent to the oldest received from CWF.

HCPCS Healthcare Common Procedure Coding System(HCPCS) - This field identifies the HCPC code of 'G0375'or 'G0376'. This is a five-position alphanumeric field.

FROM From Date - This field identifies the from date of theclaim. This is a ten-position alphanumeric field inMM/DD/CCYY format.

THRU Through Date - This field identifies the through date ofthe claim. This is a ten-position alphanumeric field inMM/DD/CCYY format.

PER Period – This field identifies up to five years of counselingdata. This is a one-position alphanumeric field. The validvalues are:'1' One year'2 Two years'3' Three years'4' Four years'5' Five years

QT Quantity – This field identifies the number of servicesbilled for each date. This is a one-position alphanumeric field.

NOTE: Services are multiple services per quantity billed.(i.e., 10/25/2005 - 10/25/2005 units 2 post as 2 sessions.)

TP Claim Type – This field identifies the claim type. This is aone-position alphanumeric field. The valid values are:'O' Outpatient'B' Part B


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Eligibility Detail Inquiry Screen 10 (MAP 175L)

9. From the Eligibility Detail Inquiry Screen 9 (MAP 175K), press < F8 > to displaythe Eligibility Detail Inquiry Screen 10 (MAP175L)

MAP175L NOVITAS SOLUTIONS ACMMAWM2 10/05/10ABC0000 SC HOME HEALTH CERTIFICATION C201044S 12:44:09

REQ DATE HIC DOBmmdyy NAME

REC HCPCS FROM DATE REC HCPCS FROM DATE


Field Descriptions for MAP175L

Note : This screen is used for Home Health Certification Plan of Care data. Itdisplays up to 20 occurrences of Healthcare Common Procedure Coding (HCPC)codes 'G0179' and 'G0180' with dates for certification up to nine months prior to thecurrent date.

ex. ACMMAWM2 Region

ex. 10/05/10 Date

ex. ABC0000 User ID

ex. C201044S Release

ex. 12:44:09 Time

REQ DAT Request Date – This field identifies the date ofrequest. This is a six-position alphanumeric field inMMDDYY format.


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HIC Health Insurance Claim Number - This field identifies theHealth Insurance Claim Number used in billing the claim.This is a 12-position alphanumeric field.

NAME Name – This field identifies the name associated with theHealth Insurance Claim Number. This is a 12-positionalphanumeric field.

DOB Date of Birth – This field identifies the date of birthassociated with the Health Insurance Claim Number. Thisis a six-position alphanumeric field in MMDDYY format.

REC HCPCS Record Healthcare Common Procedure Coding System(HCPCS) – This field identifies the health insurancerecord number.

This is a 3-position alphanumeric field.FROM DATE From Date – This field identifies the Home Health from

date. This is a six-position alphanumeric field inMMDDYY format.


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10. From the Eligibility Detail Inquiry Screen 10 (MAP 175L), press < F8 > to displaythe Eligibility Detail Inquiry Screen 11 (MAP 1759).

Note: There can be up to five pages of MSP data.


MSP DATA PAGE OF

EFFECTIVE DATE: SUBSCRIBER NAME:TERMINATION DATE: POLICY NUMBER:

MSP CODE: INSURER TYPE:PATIENT RELATIONSHIP:

REMARKS CODES:

INSURER INFORMATIONNAME: GROUP NO: ADDRESS: NAME:

EMPLOYER DATANAME: EMPLOYEE ID:

ADDRESS: EMPLOYEE INFO:




ex. 06/11/09 Date

ex. ABC0000 User ID



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ex. 13:47:32 Time

SC Allows user to jump from one system application toanother. Key the two-digit application number and press

.EFFECTIVE DATE Effective Date - This field identifies the date of the

Medicare Secondary Payer (MSP) coverage.

SUBSCRIBER NAME Subscriber Name - This field identifies the first and lastname of the individual subscribing to the MSP coverage.

TERMINATION DATE Termination Date - This field identifies the date thecoverage terminates under the payer listed.

POLICY NUMBER Policy Number - This field identifies the policy numberwith the payer listed.

MSP CODE Medicare Secondary Payer Code - This field identifiesthe type of insurance coverage. This is a one positionalphanumeric field. The valid values can be foundthrough the National Uniform Billing Committee (NUBC)at http://www.nubc.org/

INSURER TYPE Insurer Type - This field is not used in Direct Data Entry.

PATIENTRELATIONSHIP Patient Relationship - This field identifies the relationship

of the beneficiary/patient to the insured under the policylisted. The valid values can be found through the NationalUniform Billing Committee (NUBC) athttp://www.nubc.org/

REMARKS CODES: Remarks Codes - This field is for intermediary use.

INSURER INFORMATION

NAME: Insurer's Name - This field identifies the name of theinsurance company, which may be primary overMedicare.

GROUP NO: Insurer Group Number - This field identifies the groupnumber for the policyholder with this insurer name.


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ADDRESS: Insurer's Address - This field identifies the street, city,state, and ZIP code for the insurer.

NAME: Group Name - This field identifies the name of the insurer

group.

EMPLOYER DATAThis data is no longer available.


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Diagnostic Related Grouping (DRG)/Prospective Payment System (PPS)

PurposeThe purpose of the DRG Pricer/Grouper screen will be to research PPS information

as it pertains to an inpatient stay.

Access1. From the MAIN MENU (MAP 1701) type 01. Press

2. From the INQUIRY MENU (MAP 1702), type 11 in the Enter Menu Selection field.Press

MAP1702 NOVITAS SOLUTIONS ACMMA871 06/11/09 ABC000 INQUIRY MENU C200931S 13:47:32

BENEFICIARY/CWF 10 ZIP CODE 19


CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56

REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67


DX/PROC CODES 15 CHECK HISTORY FI

ADJUSTMENT REASON CODES 16

REASON CODES 17

ENTER MENU SELECTION: 11PLEASE ENTER DATA – OR PRESS PF3 TO EXIT


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DT Discharge Date (MMDDYY) PROV Provider Number TOTAL CHARGE Total Charge on UB04 DOB Date of Birth MMDDYYY (Key either age or DOB)

OR AGE Age of beneficiary at time of discharge APPROVED LOS Approved length Of Stay; Must equal CoveredDays

COV DAYS Covered Days; Must equal approved Length ofStay

MAP1781 NOVITAS SOLUTIONS ACMMAWM2 06/07/11 ABC0000 SC DRG/PPS INQUIRY C2011300 08:22:54

DIAGNOSES: 1 2 3 4 56 7 8 9 POA

PROCEDURES: 1 2 3 4 56 7 8 9 NPI

SEX C-I DISCHARGE STATUS DT PROVREVIEW CODE TOTAL CHARGES DOB OR AGE

APPROVED LOS COV DAYS LTR DAYS PAT LIABRETURNED FROM GROUPER: GROUPER VERSION

D.R.G. MAJOR DIAG CAT RETURN CODEPROC CD USED DIAG CD USED SEC DIAG USED

RETURNED FROM PRICER: PRICER VERSIONRTN CD WAGE INDEX OUTLIER DAYS

AVG# LENGTH OF STAY OUTLIER DAYS THRESHOLDOUTLIER COST THRES INDIRECT TEACHING ADJ#TOTAL BLENDED PAYMENT HOSPITAL SPECIFIC PORTIO

NFEDERAL SPECIFIC PORTION DISP# SHARE HOSPITAL AMTPASS THRU PER DISCHARGE OUTLIER PORTIONPTPD + TEP STANDARD DAYS USEDLTR DAYS USED PROV REIMB

PLEASE ENTER DATA, PF3-EXIT, PF6-FWD, PF8-COST DISCLOSURE, ENTER-PROCESS

4. Press . The DRG grouper information will appear.5. F8 to view Cost Disclosure Inquiry (MAP1782 – MAP1784))


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Field Descriptions for DRG/PPS Inquiry Screen (MAP 1781)

Note: MAP numbers reference FISS screens. MAP numbers are listed in the upperleft corner of the screen, and page numbers are listed in the upper right corner of the

screen.ex. ACMMA8971 Region

ex. 06/11/09 Date

ex. ABC0000 User ID


ex. 13:47:32 Time


DIAG CD Diagnosis Codes – This field identifies up to nineInternational Classification of Diseases, 9 th Revision,Clinical Modification (ICD-9-CM) codes for conditionscoexisting on a particular claim. The decimal point is notused.

Note: Refer to the ICD-9-CM manual for the valid values.

PROC CD Procedure Codes – The ICD-9-CM procedure code(s)identifies the principal procedure (1 st code) and up to fiveother procedures performed during the billing periodcovered by this claim.

NPI NPI – This field identifies the National Provider Identifiernumber. This is a ten-position alphanumeric field.

SEX Beneficiary Sex – This field identifies the beneficiary ‘ssex. This is a one position alphanumeric field. The validvalues are:M MaleF Female


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C-I Century Indicator – This field identifies the correctcentury in which the beneficiary was born. The validvalues are:8 If the beneficiary was born in the 1800 ‘s.

9 If the beneficiary was born in the 1900 ‘s.DISCHARGE STATUS Discharge Status – This field identifies the status of the

patient at the statement through date.

DT Discharge Date – This field identifies the date on whichthe patient was discharged from the type of care. Theformat is MMDDYY.

PROV Provider Number – This field displays the identificationnumber of the provider. It is system generated for

providers.REVIEW CODE Review Code – This field identifies the code used in

calculating the standard payment. The valid values are:00 Pay with outlier – use of this code calculates the

standard payment and attempts to pay day andcost outliers.

01 Pay days outlier – use of this code calculates thestandard payment and calculates the day outlierportion of the payment if the covered days exceedthe outlier cutoff for the DRG.

02 Pay cost outlier – use of this code calculates thestandard payment and calculates the cost outlierportion of the payment if the adjusted charges onthe bill exceed the cost threshold. If the length ofstay exceeds the outlier cutoff, no payment ismade and a return code of ‗60 ‘ is returned.

03 Pay per diem days – use of this code calculates aper diem payment based on the standard paymentif the covered days are less than the averagelength of stay for the DRG. If the covered daysequal or exceed the average length of stay thestandard payment is calculated.


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04 Pay average stay only – use of this codecalculates the standard payment, but it does nottest for days or cost outliers.

05 Pay transfer with cost – use of this code, pays

transfer with cost outlier approved.06 Pay transfer no cost – use of this code, paystransfer with cost outlier denied.

07 Pay without cost – use of this code, pays withoutcost outlier.

TOTAL CHARGES Total Charges – This field identifies the covered chargesas submitted on the claim.

DOB Beneficiary ‘s Date of Birth – This field identifies the dateof birth for the beneficiary. The format is MMDDYYYY.

OR AGE Beneficiary ‘s Age – This field identifies the age of thebeneficiary. This or the date of birth may be used toidentify the age of the patient.

APPROVED LOS Approved Length of Stay – This field identifies theapproved number of days for treatment. This field isnecessary for the Pricer to determine whether day outlierstatus is applicable in non-transfer cases, and in transfercases, to determine the number of days for which to paythe per diem rate

COV DAYS Covered Medicare Days – This field identifies the numberof Medicare Part A days covered for this claim.

LTR DAYS Lifetime Reserve Days – This field identifies the numberof Lifetime Reserve Days used for a particular claim.

PAT LIAB Patient Liability Due – This field identifies the dollaramount owed by the beneficiary to cover anycoinsurance days or non-covered days or charges. Theformat is 999999.99.


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20 Bad revenue code for Skilled Nursing Facility(SNF) Resource Utilization Group (RUG) Demo orinvalid Health Insurance Prospective PaymentSystem (HIPPS) code for SNF ProspectivePayment System (PPS) Pricer.

30 Bad Metropolitan Statistical Area (MSA) Code.Return codes 50 – 99 describe why the bill was notpriced: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 indicates day

outlier. Bill is thus not eligible as cost outlier.61 Lifetime reserve days not numeric.62 Invalid number of covered days (i.e., more than

approved length of stay, non-numeric, or lifetimereserve days greater than covered days).

63 Review code of ‗00 ‘ or ‗03 ‘, and bill is cost outliercandidate.

64 Disproportionate share percentage and bed sizeconflict on provider specific file.

98 Cannot process bill older than 10/01/87.

PROC CD USED Procedure Code Used – This field identifies theprocedure code used by the Grouper program forcalculation. The procedure code is an InternationalClassification of Diseases, 9 th Revision, ClinicalModification (ICD-9-CM) code that identifies the principalprocedure(s) performed during the billing period coveredby this claim.

DIAG CD USED Diagnosis Code Used – This field identifies the primaryICD-9-CM diagnosis code used by the Grouper programfor calculation.

SEC DIAG USED Secondary Diagnosis Code Used – This field identifiesthe secondary ICD-9-CM diagnosis code used by theGrouper program for calculation.


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GROUPER VER Grouper Version Number – This field displays theprogram identification number for the Grouper programused.

RETURNED FROM PRICERRTN CD Return Code – This field identifies the status of the claimwhen it has returned from the Pricer program. The validvalues are:

Return codes 00 – 49 describe how the bill was priced:00 Priced standard Diagnosis Related Group (DRG)

payment.01 Paid as day outlier02 Paid as cost outlier03 Paid as per diem/not potentially eligible for cost

outlier.04 Standard DRG, but covered days indicate dayoutlier but day or cost outlier status was ignored.

05 Pay per diem days plus cost outlier for transferswith an approved cost outlier.

06 Pay per diem days only for transfers without anapproved outlier.

10 Bad state code for Skilled Nursing Facility (SNF)Resource Utilization Group (RUG) Demo or Post

Acute Transfer for Inpatient Prospective PaymentSystem (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 > average length of stay.

16 Paid as a Cost Outlier with per diem days = or >average length of stay.

20 Bad revenue code for SNF RUG Demo or invalidHIPPS code for SNF PPS Pricer.

30 Bad Metropolitan Statistical Area (MSA) Code.


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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 startdate.

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 not numeric.62 Invalid number of covered days (i.e., more than

approved length of stay, non-numeric, or lifetimereserve 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 Wage Index – This field identifies the wage index assupplied by CMS to be used for the state in which theservices were provided to determine reimbursementrates for the services rendered.

OUTLIER DAYS Outlier Days – This field identifies the number of daysbeyond the cutoff point for the applicable DRG.

AVG #LENGTH OF STAY Average Length of Stay – This field identifies the CMS

predetermined length of stay based on certain claim data.

OUTLIER DAYSTHRESHOLD Outlier Days Threshold – This field identifies the number

of days of utilization permissible for the DRG code in thisclaim.


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OUTLIER COSTTHRES Outlier Cost Threshold – If the claim has extraordinarily

high charges and does not qualify as a day outlier, thenthe claim may qualify as a cost outlier.

INDIRECTTEACHING ADJ # Indirect Teaching Adjustment – This field identifies the

amount of the adjustment calculated by the Pricerprogram for teaching hospitals.

TOTAL BLENDED PAYMENT Total Blended Payment – This field identifies the total

PPS payment amount consisting of the Federal, hospital,outlier and indirect teaching reductions (such as GrammRudman) or additions (such as interest).

HOSPITAL SPECIFIC PORTION Hospital Specific Portion – This field identifies the

hospital portion of the total blended payment used inreimbursing this Prospective Payment System (PPS)claim.

FEDERALSPECIFIC PORTION Federal Specific Portion – This field identifies the Federal

portion of the total blended payment used in reimbursingthis PPS claim.

DISP # SHAREHOSPITAL AMT Disproportionate Share Hospital Amount – This field

identifies the percentage of a hospital total Medicare Part A patient days attributable to Medicare patients who arealso SSI. Medicaid days and total days are available onthe hospitals ‘ cost reports.

PASS THRUPER DISCHARGE Pass Through Per Discharge – This field identifies the

pass through per discharge cost.


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OUTLIER PORTION Outlier Portion – This field identifies the dollar amountcalculated that reflects the outlier portion of the charges.

PTPD + TEP Pass Through Per Discharge Plus Total Blended

Payment – This field is simply the sum of the passthrough per discharge cost plus the total blendedpayment amount.

STANDARDDAYS USED Standard Days Used – This field identifies the number of

regular Medicare Part A days covered for this claim.

LTR DAYS USED Lifetime Reserve Days Used – This field identifies thenumber of Lifetime Reserve Days used during this benefitperiod.

PROV REIMB Provider Reimbursement Amount – This field identifiesthe actual payment amount to the provider for this claim.This is the amount on the Remittance Advice/Voucher.

PRICER VER Pricer Version Number – This field identifies the programversion number for the Pricer program used.

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