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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.

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    Local B/MAC/Carrier Receives a Claim for Services that are in Another Local B/MAC/Carrier’s Payment Jurisdiction


    When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.

    NOTE: This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, but are billed to the wrong B MAC/carrier payment jurisdiction.

    Use the following messages for claims indicated above except for claims that are identified as UMWA or RRB claims:

    Claim Adjustment Reason Code (CARC) 109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

    Remittance Advice Remark Code (RARC) N104 - This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at www.cms.gov.

    RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information


     A Local B/MAC/Carrier Receives a Claim for Services that are in A DME MAC’s Payment Jurisdiction

    When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a DME MAC’s payment jurisdiction, the claim shall be returned as unprocessable.

    Use the following messages for claims indicated above except for claims that are identified as UMWA or RRB claims:

    CARC 109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

    RARC N104 - This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at www.cms.gov.

    RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.


    - A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carrier’s Payment Jurisdiction

    When a local DME MAC receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carrier’s payment jurisdiction, the claim shall be returned as unprocessable.

    Use the following messages for claims indicated above except for claims that are identified as UMWA claims:

    CARC 109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

    RARC N104 - This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at www.cms.gov.

    RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.


     A Local B/MAC/Carrier Receives a Claim for an RRB Beneficiary

    When a local contractor (Part B MAC or carrier) receives a Form CMS-1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable.

    Use the following messages:

    CARC 109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

    RARC N105 - This is a misdirected claim/service for a RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing.

    RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is  unprocessable. Please submit a new claim with the complete/correct information.

    NOTE: CMS requests that when RRB receives a claim that is not for an RRB beneficiary that they return the claim to the sender and notify them that the claim must be submitted to the local contractor (Part B MAC or carrier) or DME MAC for processing.


    - A Local B/MAC/Carrier/DME MAC Receives a Claim for a UMWA Beneficiary

    When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS-1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.

    Use the following messages:

    CARC 109 - Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

    RARC N127 – This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.

    RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

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    FL 6. Statement Covers Period (From - Through)
    a. Cannot exceed eight positions in either “From” or “Through” portion allowing for separations (nonnumeric characters) in the third and sixth positions.
    b. The “From” date must be a valid date that is not later than the “Through” date.
    c. The “Through” date must be a valid date that is not later than the current date.
    d. With the exception of Home Health PPS claims, the statement covers period may not span 2 accounting years.


    FL 09. Patient’s Address
    a. The address of the patient must include:
    City
    State (P.O. Code)
    ZIP
    b. Valid ZIP Code must be present if the type of bill is 11X, 13X, 18X, or 83X or 85X.
    c. Cannot exceed 62 positions.


    FL 10. Birthdate
    a. Must be valid if present.
    b. Cannot exceed 10 positions allowing for separations (nonnumeric characters) in the third and sixth positions.


    FL 11. Sex
    a. One alpha position.
    b. Valid characters are “M” or “F.”
    c. Must be present.

    FL 12. Admission Date
    a. Must be valid if present.
    b. Cannot exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions.
    c. Present only if the type of bill is 11X, 12X, 18X, 21X, 22X, 32X, 33X, 41X, 81X or 82X.

    FL 14. Priority (Type) of Admission or Visit
    a. One numeric position.
    b. Required only if the type of bill is 11X, 12X, 18X, 21X, 22X, or 41X.


    FL 15. Point of Origin for Admission or Visit.
    a. One numeric position
    b. Must be present

    FL 17. Patient Discharge Status.
    a. Two numeric positions
    b. Present on all Part A inpatient, SNF, hospice, home health agency, and outpatient hospital services. Types of bill: 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, or 85X.

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    FLs 18 thru 28. Condition Codes.
    a. Each code is two numeric digits.
    b. If code 07 is entered, type of bill must not be hospice 81X or 82X.
    c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.
    d. If code 40 is entered, the “From” and “Through” dates in FL 6 must be equal, and there must be a “0” or “1” in FL 7 (Covered Days).
    e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.


    FLs 31, 32, 33, and 34. Occurrence Codes and Dates
    a. All dates must be valid.
    b. Each code must be accompanied by a date.
    c. All codes are two alphanumeric positions.
    d. If code 20 or 26 is entered, the type of bill must be 11X or 41X. If code 21 or 22 is entered, the type of bill must be 18X or 21X.
    e. If code 27 is entered, the type of bill must be 81X or 82X.
    f. If code 28 is entered, the first digit in FL 4 must be a “7” and the second digit a “5.”
    g. If code 42 is entered, the first digit in FL 4 must be “8” and the second digit “1” or “2” and the third digit “1 or 4.”
    h. If 01 - 04 is entered, Medicare cannot be the primary payer, i.e., Medicare-related entries cannot appear on the “A” lines of FLs 58-62.
    i. If code 20 is entered:
    • Must not be earlier than “Admission” date (FL 17) or later than “Through” date (FL 6).
    • Must be less than 13 days after the admission date (FL 17) if “From” date is equal to admission date (less than 14 days if billing dates cover the period December 24 through January 2).
    j. If code 21 is entered:
    • Cannot be later than “Statement Covers Period” Through date; or
    • Cannot be more than 3 days prior to the “Statement Covers Period” From date.
    k. If code 22 is entered, the date must be within the billing period shown in FL 6.


    FL 35 and 36. Occurrence Span Codes and Dates
    a. Dates must be valid.
    b. Code entry is two alphanumeric positions.
    c. Code must be accompanied by dates.
    d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.
    e. If code 71 is entered, the first digit of FL 4 must be “1,” “2,” or “4” and the second digit must be “1.”
    f. If code 72 is entered, the type of bill must be 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, or 85X.
    g. If code 74 is entered, the type of bill must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 74X, 75X, 81X, or 82X.
    h. If code 75 is entered, the first digit of FL 4 must be “1” or “4” and the second digit must be “1.”
    i. If code 76 is entered, occurrence code 31 must be present (inpatient only).
    j. If code 76 is entered, occurrence code 32 must be present (outpatient only).
    k. If code 76, 77, or M1 is present, the bill type must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 73X, 74X, 75X, 81X, 82X, or 85X.
    l. Neither the “From” nor the “Through” portion can exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions of each field.
    m. If code M2 is present, the bill type must be 81X or 82X.
    n. Code 79 is for payer use only. Providers do not report this code.

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    FL 76. Attending Provider Name and Identifiers.

    a. The UPIN must be present on inpatient Part A bills with a “Through” date of January 1, 1992, or later. For outpatient and other Part B services, the UPIN must be present if the “From” date is January 1, 1992, or later. This requirement applies to all provider types and all Part B bill types. Effective May 23, 2007, providers are required to submit NPI.

    b. An institutional provider may not submit their own NPI, except for Institutional billing of influenza and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of influenza and pneumococcal vaccinations and their administrations, self-referred screening mammography as the only billed service on a claim, or where the provider only has a type-1 NPI as a physician/practitioner owned sole-proprietor.


    FL 77. Operating Physician Name and Identifiers

    a. Effective May 23, 2007, providers are required to submit NPI. NPI must be present if:
    • Bill type is 11X and a procedure code is shown in FL 74;
    • Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or
    • Bill type is 85X and HCPCS code is in the range of 10000 through 69979.
    b. If required:
    • NPI, last name and first initial must be present; and
    • Left justified.

    FL 56. National Provider Identifier – Billing Provider
    a. Effective May 23, 2007, providers are required to submit their NPI.
    b. Left justified.

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    FL 76. Attending Provider Name and Identifiers.

    a. The UPIN must be present on inpatient Part A bills with a “Through” date of January 1, 1992, or later. For outpatient and other Part B services, the UPIN must be present if the “From” date is January 1, 1992, or later. This requirement applies to all provider types and all Part B bill types. Effective May 23, 2007, providers are required to submit NPI.

    b. An institutional provider may not submit their own NPI, except for Institutional billing of influenza and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of influenza and pneumococcal vaccinations and their administrations, self-referred screening mammography as the only billed service on a claim, or where the provider only has a type-1 NPI as a physician/practitioner owned sole-proprietor.


    FL 77. Operating Physician Name and Identifiers

    a. Effective May 23, 2007, providers are required to submit NPI. NPI must be present if:
    • Bill type is 11X and a procedure code is shown in FL 74;
    • Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or
    • Bill type is 85X and HCPCS code is in the range of 10000 through 69979.
    b. If required:
    • NPI, last name and first initial must be present; and
    • Left justified.

    FL 56. National Provider Identifier – Billing Provider
    a. Effective May 23, 2007, providers are required to submit their NPI.
    b. Left justified.

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     Credentialing Criteria

    At a minimum, eligible providers must meet the criteria listed below before they can participate in the 1199SEIU Benefit Funds’ network:

    1. A valid, current, unencumbered license to practice issued by the state education department within the state of practice.

    2. Graduation from an accredited medical school, professional school, college of osteopathy or a foreign medical school recognized by the World Health Organization and completion of a residency program.

    3. Foreign medical school graduates must submit an ECFMG certification (if licensed after 1986).

    4. Current, active medical staff privileges (if applicable) in good standing at a participating hospital.

    5. Evidence of at least five years of work history. (“Work” includes time spent in the past five years – post-fellowship, military service, etc.).

    6. Professional liability insurance in the amount of $1 million per incident/$3 million aggregate per annum.

    7. Current Drug Enforcement Agency (DEA) registration, where applicable.

    8. For MDs and DOs only, board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association. For an applicant who is not board-certified, sufficient work history (the practitioner must be in practice for 20 or
    more years) and evidence of significant network need in a local area will be considered. The credentialing committee will make this determination on a case-by-case basis.

    9. For MDs only, current and unencumbered participation in the Medicaid and Medicare programs or proof that such non-participation is entirely voluntary and not due to current or past debarment from the programs.

    10. Absence of a physical or mental impairment or condition that may impede the provider’s performance of essential functions of his/her clinical responsibility. If the provider does have a physical or mental impairment, he or she must submit adequate evidence that a physical or mental impairment or condition does not render the provider unable to perform the essential functions without threatening the health or safety of others.

    11. Absence of a current chemical dependency or substance abuse problem. For an applicant with this history, the provider must submit adequate evidence that a past chemical  dependency or substance abuse problem does not adversely affect the provider’s ability to
    competently and safely perform essential functions.

    12. Absence of a history of professional disciplinary actions or absence of any other information that may indicate provider is engaged in unprofessional misconduct. Unprofessional misconduct can be defined as, but not limited to, sexual misconduct (e.g., with patients), sexual harassment of his or her patients or fraudulent billing practices.
    An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

    13. Absence of a history of felony criminal conviction or indictment. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

    14. Absence of falsification of the credentialing application, requested documents or material omission of information requested in the  pplication.

    At the Time of Re-Credentialing:

    15. Absence of information to indicate a pattern of inappropriate utilization of medical resources.

    16. Absence of substantiated member complaints. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

    17. All criteria applicable to original credentialing must still be true.

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    Re-Credentialing

    All providers must be re-credentialed every three years to continue their participation with the 1199SEIU Benefit Funds. Re-credentialing allows us to re-evaluate qualifications and performance and ensure compliance with the 1199SEIU Benefit Funds’ criteria. Providers may be re-credentialed off-cycle for disciplinary actions, a suspended license, cancellation of professional liability coverage, loss of privileges, suspected fraudulent behavior and quality-of-care or member dissatisfaction concerns.

    Any fraudulent or erroneous information submitted to the 1199SEIU Benefit Funds, including at the time of the original credentialing, can be cause for a provider to immediately lose his or her participation status with the 1199SEIU Benefit Funds. Providers are obligated  to immediately notify the 1199SEIU Benefit Funds of changes to any information submitted as part of the credentialing and re-credentialing processes.


    Delegated Credentialing

    In certain instances, providers may be credentialed through “delegated credentialing,” whereby an outside entity authorized by the 1199SEIU Benefit Funds (generally a hospital) will credential the provider. That provider still must sign a contract directly with the 1199SEIU Benefit Funds and pass the 1199SEIU Benefit Funds’ onsite auditing process. However, the 1199SEIU Benefit Funds retain the final authority to approve, terminate or suspend a provider at their sole discretion. The 1199SEIU Benefit Funds may delegate credentialing to contracted facilities, organizations or provider groups who demonstrate the ability, through a pre-delegation assessment, to meet the performance requirements of the 1199SEIU Benefit Funds. Approved delegates may be evaluated annually to monitor continued compliance with the
    1199SEIU Benefit Funds’ current credentialing criteria.


     Facility and Ancillary Provider Credentialing

    The 1199SEIU Benefit Funds have established facility and ancillary criteria for evaluating and appointing providers to its network. This facility and ancillary application assesses and gathers appropriate certification data and also verifies the extensive list of services provided by our
    facilities for areas such as behavioral health, mental health, substance abuse, durable medical equipment, orthotics and prosthetics, home health/hospice, freestanding ambulatory surgery,  and rehabilitation and dialysis.

    Please contact the Provider Relations Department to speak to one of our representatives about applying to be a participating Ancillary Provider.

    The 1199SEIU Benefit Funds are committed to protecting the confidentiality of all provider information obtained during the credentialing process.

    Please note that participating hospitals, treatment centers, ancillary facilities, group and individual providers should notify the Provider

    Relations Department of new providers joining  (and leaving) existing practices.

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  • 07/26/16--03:10: CLIA Number on UB 04 form

  •  
    “CLIA”  - The Clinical Laboratory Improvement Act and CMS implementing regulations and processes.  

    A paper claim for laboratory testing requires the presence of the CLIA number of the lab performing the testing in field 64 on UB04 form

      If a valid and appropriate CLIA number is not included with the claim as provided in this letter, the entire claim will not be considered a clean claim and will be rejected as incomplete. This process is consistent with the procedure followed by CMS and is applicable to all products offered by MHS.

    •    Physician office laboratory services follow CLIA regulations and are required to bill the CLIA or Waiver number on each appropriate service.

    •    A list of CLIA laboratories can be found at www.cdc.gov/clia/Resources/LabSearch.aspx



    Electronic Claim Submission to Carriers

    American National Standards Institue (ANSI) X12N 837 (HIPAA version) format electronic claims: 

    CLIA number: 
    An ANSI claim for laboratory testing will require the presence of the performing (and billing) laboratory’s CLIA number; if tests are referred to another laboratory, the CLIA number of the laboratory where the testing is rendered must also be on the claim.  

    An ANSI electronic claim for laboratory testing must be submitted using the following format: 


    ANSI Electronic claim: the billing laboratory performs all laboratory testing.

    The independent laboratory submits a single claim for CLIA-covered laboratory tests and reports the billing laboratory’s number in: 
    X12N 837 (HIPAA version) loop 2300, REF02.   REF01 = X4 

    ANSI Electronic claim: billing laboratory performs some laboratory testing; some testing is referred to another laboratory.

    The ANSI electronic claim will not be split; CLIA numbers from both the billing and reference laboratories must 
    be submitted on the same claim.  The presence of the ‘90’ modifier at the line item service identifies the referral 
    tests.  Referral laboratory claims are only permitted for independently billing clinical laboratories, specialty code 69. 

    The billing laboratory submits, on the same claim, tests referred to another (referral/rendered) laboratory, with 
    modifier 90 reported on the line item and reports the referral laboratory’s CLIA number in: 
    X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4 

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    If Fraud or Abuse of Benefits Is Suspected

    If the Fraud and Abuse Department suspects potential fraud or abuse because of evidence such as reimbursement data, information from law enforcement or fraud organizations or complaints from members, providers, provider employees, vendors or 1199SEIU Benefit Funds’ staff, the 1199SEIU Benefit Funds will review the claim(s) in question and assign an investigator.

    This investigation may include:

    • Pre/post payment claims review;

    • Medical record request and review;

    • Data analysis;

    • Verification of services (surveying patients, auditing charts);

    • Onsite field audit request; and

    • Provider monitoring.



    Provider Notification

    The Fraud and Abuse Department will notify providers of any investigations that may adversely affect payment.



    Providers Have the Right to Challenge Fraud and Abuse Determinations

    Providers have the right to challenge the 1199SEIU Benefit Funds’ initial fraud and abuse determinations. The provider may request a second review by the Fraud and Abuse Committee.

    Decisions made in a court or by settlement may not be appealed to the 1199SEIU Benefit Funds.

    If the appeal is unsuccessful, the 1199SEIU Benefit Funds will begin to recover lost monies by negotiating a settlement with the provider. If no settlement agreement can be reached, the 1199SEIU Benefit Funds will take whatever action is necessary to recover lost monies, such
    as suspending future payments. Unsuccessful recovery efforts will ultimately result in removal from the 1199SEIU Benefit Funds’ network of participating providers; in some cases the 1199SEIU Benefit Funds may refer the provider to law enforcement and/or licensing boards.

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    Loop ID Reference Name Codes Notes/Comments
     
    1000A NM1 Submitter Name  

    1000A NM109 Submitter Identification Code The existing trading partners will continue using the six-digit submitter code. Tufts Health Plan will work with new trading partners prior to implementation to determine the six-digit submitter code.  

    2010AB Pay-To Address NameThis loop has been changed to indicate a separate address for payments to the Billing Provider. Please note that Tufts Health Plan will continue making payments to the address in our backend system database instead of the address submitted in 2010AB.  

    2000B SBR Subscriber Hierarchical Level  

    2000B SBR01 Payer Responsibility Sequence Number Code This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment.  

    2010BA NM1 Subscriber Name


    2010BA NM109 Identification CodeEach Tufts Health Plan member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in Element NM109 of Loop 2010BA.  

    2010CA NM1 Patient NameEach Tufts Health Plan member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. Tufts Health Plan will not accept any data in the Patient Loop and will REJECT accordingly.  

    2300 REF Payer Claim Control Number  

    2300 REF02 Reference Identification For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. Tufts Health Plan also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4.  

    2300 HI01-2 Occurrence Code If a claim is accident or employment related, Tufts Health Plan requires the appropriate occurrence code. We will only process one iteration of HI01.  

    2300 HI01-4 Date Time Period If a claim is accident or employment related, Tufts Health Plan requires the appropriate occurrence date. We will only process one iteration of HI01.


    2310E NM1 Service Facility Location Name Tufts Health Plan REQUIRES that Service Facility Information always match Billing Provider Information given that the payee should always equal the provider on institutional claims.  

    2320 Other Subscriber Information  

    2320 SBR Other Subscriber Information Required by Tufts Health Plan to understand the payer responsibility sequence.  

    2320 AMT COB Payer Paid Amount Tufts Health Plan requires the total amount paid at the claim level.  

    2330A NM1 Other Subscriber NameTufts Health Plan requires this segment for COB claims.  

    2330B NM1 Other Payer NameTufts Health Plan requires this segment for COB claims.  

    2430 SVD Line Adjudication Information  

    2430 SVD02 Monetary Amount Tufts Health Plan requires the amount paid by the payer in 2330B for this line.  

    2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligations Used to validate total amount billed in SV1 segment.  

    2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility Also used to validate total amount billed in SV1 segment. (if applicable)



    1000A NM1 Submitter Name  

    1000A NM109 Submitter Identifier The existing trading partners will continue using the six-digit submitter code. Tufts Health Plan will work with new trading partners prior to implementation to determine the six-digit submitter code.  

    2010AB Pay-To Address NameThis loop has been changed to indicate a separate address for payment to the Billing Provider. Please note that Tufts Health Plan will continue making payments to the address in our backend system database instead of the address submitted in 2010AB.  

    2000B SBR Subscriber Hierarchical Level  

    2000B SBR01 Payer Responsibility Sequence Number Code This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment.  

    2010BA NM1 Subscriber Name  

    2010BA NM109 Identification Code Each Tufts Health Plan member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in NM109 of loop 2010BA.  

    2010CA NM1 Patient Name Each Tufts Health Plan member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should be submitting member ID in Element NM109 of Loop 2010BA. Thus Tufts Health Plan will not accept any data in the Patient Loop and will REJECT accordingly.


    2300 REF Payer Claim Control Number  

    2300 REF02 Reference Identification For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. Tufts Health Plan also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4.  

    2320 Other Subscriber Information  

    2320 SBR Other Subscriber Information Required by Tufts Health Plan to understand the Payer Responsibility sequence.  

    2320 AMT COB Payor Paid Amount Tufts Health Plan requires the total amount paid at the claim level.  

    2330A NM1 Other Subscriber Name Tufts Health Plan requires this segment for COB claims.  

    2330B NM1 Other Payer Name Tufts Health Plan requires this segment for COB claims.  

    2430 SVD Line Adjudication Information  

    2430 SVD02Monetary Amount Tufts Health Plan requires the amount paid by the payer in 2330B for this line.  

    2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligation Used to validate total amount billed in SV1 segment.  

    2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility Also used to validate total amount billed in SV1 segment. (if applicable)



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    Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC


    A “misdirected claim” is a claim that has been submitted to the wrong place. This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.

    Each fee-for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing. Physicians and other suppliers are required to submit claims to the contractor having the appropriate jurisdiction. Jurisdictional rules are specified in this Chapter at Section 10.

    A contractor may not knowingly adjudicate a misdirected claim and, as such, upon receipt of such a claim, must dispose of the claim in accordance with the specifications of this section or other relevant instructions.


    This section addresses the following types of misdirected claims:

    1. a CMS-1500 or electronic claim submitted to the wrong local contractor (Part B MAC or carrier);

    2. a CMS-1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to a DME MAC;

    3. a CMS-1500 or electronic claim submitted to a DME MAC that should have been submitted to a local contractor (Part B MAC or carrier);

    4. a CMS-1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to the Railroad Retirement Board (RRB);

    5. a CMS-1500 or electronic claim submitted to a DME MAC or a local contractor (Part B MAC or carrier) that should have been submitted the United Mine Workers of America (UMWA);

    6. a CMS-1500 claim that should be submitted to a DME MAC that is submitted to the wrong DME MAC, and

    This subsection does not apply to:

    1. misdirected beneficiary-submitted claims. See Section 80.3.2 of this Chapter regarding handling of such claims;

    2. electronic claims for durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) that are submitted to the incorrect DME MAC (misdirected DMEPOS claims are automatically routed to the appropriate DME MAC jurisdiction for processing);

    3. a claim submitted to the wrong Part A MAC or fiscal intermediary (FI), including a regional home health intermediary (RHHI).

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    Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti-Markup Payment Limitation -

    A. General

    A physician or other supplier may bill and receive payment for the technical component (TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic laboratory test) that is performed by a physician or other supplier with whom the billing physician or other supplier does not share a practice. Reimbursement for that service is subject to the anti-markup payment limitation. If a physician or other supplier’s bill or a request for payment includes a charge for a diagnostic test (other than a clinical diagnostic laboratory test) which the physician or other supplier did not personally perform or supervise, then payment for the test may not exceed the lesser of:

    • The performing physician’s net charge to the billing physician or other supplier (net any discounts);

    • The billing physician’s actual charge; or

    • The fee schedule amount that would be allowed for the test if the performing physician or other supplier billed directly.

    For payment to be made, the physician who acquires the TC or PC of a diagnostic test from an outside source must identify the performing physician or other supplier on the claim. (The billing physician or other supplier should maintain a record of the performing physician or other supplier’s NPI in the clinical record for auditing purposes.)

    The billing physician or other supplier must also indicate on the claim that the test is subject to the anti-markup payment limitation.

    See the guidelines at http://www.wpc-edi.com/ for how to show this on electronic claims.

    If using the CMS-1500 paper claim form:

    • In item 20 check "yes" to indicate the test is subject to the anti-markup payment limitation and enter the amount the performing physician or other supplier charged.

    • In item 32 enter the name, address, and NPI of the performing physician or supplier. If the performing physician provides the service outside the A/B MAC (B) jurisdiction where the billing physician is located, the billing physician must submit its own NPI with the name, address, and ZIP code of the performing physician or other supplier.

    No payment may be made to the physician without this information unless the statement “No anti-markup tests are included” is annotated on the claim.

    NOTE: If the billing physician performs only the TC or the PC and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically or on separate claims if billing on paper (CMS-1500). Global billing is not allowed unless the billing physician or other supplier performs both components.

    Effective for claims submitted with a receipt date on and after October 1, 2015, the billing physician or supplier must report the name, address, and NPI of the performing physician or supplier in Item 32a of the CMS-1500 claim form (or its electronic equivalent) on anti-markup claims, even if the performing physician or supplier is enrolled in a different A/B MAC (B) jurisdiction. (See §10.1.1.2 for more information regarding claims filing jurisdiction.)

    B. Unassigned Claims with Required Documentation


    A physician or other supplier may not bill an individual an amount in excess of Medicare’s payment, except for any deductible and coinsurance, for the TC or PC of a diagnostic test that is subject to the anti-markup payment limitation. A/B MACs (B) must notify physicians and other suppliers that they must indicate when a diagnostic test was acquired, identify the performing physician or other supplier, and show the amount the performing physician or other supplier charged. The notification must inform physicians and other suppliers that they are prohibited by §1842(n)(3) of the Act from billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance. Excess amounts collected from the beneficiary must be repaid.

    C. Unassigned Claims without Required Documentation

    A physician may not bill a beneficiary:

    • If the bill does not indicate who performed the test; and

    • If the bill indicates that a separate physician or other supplier performed the test, it does not identify the performing physician or other supplier or does not include the amount the performing physician or other supplier charged.

    The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of a diagnostic test subject to the anti-markup payment limitation is received from either the physician or a beneficiary except when the physician submits an assigned claim and the beneficiary submits an unassigned duplicate claim. They use the following sample letter.

    Dear Doctor:

    We have received an unassigned claim for diagnostic tests furnished to the patient (Beneficiary Name), on (Date of Service). You are prohibited by §1842(n)(3) of the Social Security Act from billing or collecting any amount unless you indicate that “No anti-markup tests are included” or, if the diagnostic test was acquired, you indicate who performed the test and what the physician or other supplier charged you. Some or all of the required information is missing from your patient’s claim. If you have collected any amount from your patient, it must be refunded. This claim may be resubmitted if the required information is included.

    D. Beneficiary Information Regarding Unassigned Claims

    The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:

    • Billing the beneficiary when the necessary documentation is not supplied; and

    • Billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance, when the required documentation is submitted.

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  • 08/09/16--23:29: CPT CODE H0031
  • Assessment H0031 $93.00 Per service 

    Description - Mental health assessment, by non-physician
    Place of Service where its performed - 03, 12, 13, 31, 32, 53, 99
    Service Limits -  Daily 1 service, Yearly 4 service

    Eligible service providers  - Aide, Assistant, Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS), Counselor Trainee (CT), Doctor of Osteopathic Medicine (DO), Independent Marriage & family Therapist (IMFT), Independent Social Workers (ISW/ISW-S)

    Eligible service supervisors - Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS),  Doctor of Osteopathic Medicine (DO), Independent Marriage & family Therapist (IMFT), Independent Social Workers (ISW/ISW-S)

    As you submit new and renewing treatment plans for your Anthem members, beginning with dates of service January 1, 2014, please request ABA services using H0031, H0032, H2012, H2019 & H2014. For dates of service prior to January 1, 2014, Anthem will continue to process claims with the previously approved CPT codes until December 31, 2013. If you have authorized treatment plans dating after January 1, 2014, we will contact you to change the authorized CPT codes for those plans to the new H codes.  A schedule of the new codes and their maximum allowable amounts, effective for dates of service on and after January 1, 2014, will be available online, at our secure provider portal, on or after December 1, 2013.

     Effective January 1, 2014, the only codes payable to ABA will be H0031, H0032, H2012, H2019 & H2014. All other codes will be denied.

    Any services provided under a current authorization should be billed to match that authorization, except for authorized dates of service on or after January 1, 2014, which we will change to H codes with your assistance. Requests for concurrent reviews and/or new authorizations will reflect the coding changes and should be billed to match what is authorized. Coding other than what is reflected in an authorization for ABA services should not be billed and is not covered.


    H0031 Service Definition 

    Mental Health Assessment by non-physician (Behavioral Health Assessment and Initial Treatment Plan)

    Assessment is an integrated series of procedures conducted with an individual to provide the basis for the development of an effective, comprehensive and individualized treatment plan. It is an intensive clinical and psychosocial evaluation of an individual’s mental health and/or co-occurring (mental health/substance abuse) conditions which results in an issuance of an integrated written document. This service may be conducted by an individual or by a multidisciplinary team and includes face-to-face interview contacts with the individual; and may include the individual’s family and/or significant others, collateral contacts and other agencies to determine the individual’s problems and strengths, to identify the disability(ies), and to identify natural supports.

    An initial treatment plan, including discharge criteria and/or treatment recommendations is included as part of the assessment.


    Billing and coding Guide

    Authorized practitioners:

    ƒ Bachelor’s degree in human servicesrelated field and a combination of relevant education, training, and experience totaling four years; or ƒ LADAC; or ƒ Masters Degree in human servicesrelated field.

    NOTE: Completed assessment must be signed and dated by staff completing the assessment and, as appropriate, a masters level supervisor.


    Special Instructions:
    ƒ
     DOH will use for all individuals. ƒ For DOH school-based, use modifier TR.
    ƒ CYFD will use for mental health assessment to determine eligibility for services. Use modifier HA.
    ƒ HSD/Medicaid will use this code for PSR only. Use modifier U8.
    ƒ For multi-disciplinary team, use modifier HT. ƒ For substance abuse assessment, use modifier HF. ƒ For substance abuse/mental health assessment, use modifier HH

    H0031/2 - Initial Assessment and Plan Development Performed by masters/doctorallevel provider

    Magellan provides authorizations for the Initial FBA and plan development using H0031 code (1-hour increments) or H0032 code (15-minute increments).

    For continued services, Magellan provides the authorization in units of 15-minute increments:


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    General Instructions

    ** All NPIs on claims submitted to Tufts Health Plan must be registered with the Provider Information Department prior to transmission. Please call (888) 880-8699 x3153 to verify or register the NPIs of your organization with Tufts Health Plan.

    ** Tufts Health Plan will require a valid NPI when NM109 is used in any provider loops and will not accept Provider Secondary Identification after the mandated NPI Implementation date.

    ** New submitters must go through the appropriate set-up/authorization process in order to transmit electronic claims with Tufts Health Plan.
    Please refer to the Communications/Connectivity Component of this document for details.

    ** Tufts Health Plan will accept 837 Institutional and 837 Professional Claim Transactions for all business products, however the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file.

    ** As stated in the technical reports, a maximum of 5000 CLM segments will be accepted by Tufts Health Plan.

    ** Tufts Health Plan is adhering to structural specifications for required and situational fields as stated in the technical reports. If the incoming 837I or 837P has a single ST/SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST/SEs, only the failed ST/SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgement for notification for the ST/SEs that failed.

    ** Tufts Health Plan will capture payee information from the Billing Provider Name loop (Loop 2010AA).

    ** The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that Tufts Health Plan will continue making payments to the addresses in our backend system database instead of the addresses submitted in loop 2010AB.

    ** Tufts Health Plan cannot currently support billing for atypical provider type submissions.

    ** For Frequency Types 5, 7, and 8, (Element CLM05-3), Tufts Health Plan’s original claim number (Original Reference Number – Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4.

    ** When contacting Tufts Health Plan with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission will be assigned.

    ** The Tufts Health Plan implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted.

    ** Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together.

    ** ICD-10 Codes will not be accepted until the regulatory compliance effective date of October 1, 2014.

    ** For compliance purposes, Tufts Health Plan will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia.

    ** Tufts Health Plan is unable to accept claims submitted electronically with charges total one million dollars (or more) due to system limitations.

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     Carrier Rules for Limiting Charge

    Effective January 1, 1991, the maximum allowable actual charge (MAAC) for non-participating physicians is replaced by the limiting charge. The limiting charge is the maximum that the non-participating provider may charge the beneficiary. It also effectively replaces the special charge limits for overpriced procedure, anesthesia associated with cataract and iridectomy surgery, A-mode ophthalmic ultrasound and intraocular lenses (IOLs, and designated specialty, because the limiting charge is always less than or equal to the special charge limits.

    The limiting charge applies to all of the following services/supplies, regardless of who provides or bills for them, if the services/supplies are covered by the Medicare program and are provided:

    • Physicians’ services;

    • Services and supplies furnished incident to a physician’s services that are commonly furnished in a physician’s office;

    • Outpatient physical therapy services furnished by an independently practicing physical therapist;

    • Outpatient occupational therapy services furnished by an independently practicing occupational therapist;

    • Diagnostic tests; and

    • Radiation therapy services (including x-ray, radium, and radioactive isotope therapy, and materials and services of technicians).



    NOTE: This means that, effective for services/supplies provided on or after January 1, 1994, the limiting charge applies to drugs and biologicals provided incident to physicians’ services, to physical therapy services provided by independently practicing physical therapists, and to occupational therapy services provided by independently practicing occupational therapists. These changes are made because of provisions in OBRA 1993. OBRA 1993 expanded the limiting charge to apply to services/supplies which the law permits Medicare to pay for under the physician fee schedule methodology but which Medicare has chosen to pay for under some other method. “Incident to” drugs and biologicals, previously excluded from the limiting charge because of their exclusion from physician fee schedule payment, are, effective January 1, 1994, still excluded from physician fee schedule payment but subject to the limiting charge. Also, OBRA 1993 applies the limiting charge to all of the above listed services/supplies, regardless of who provides or bills for the services/supplies. No longer are services of suppliers and other nonphysicians, such as physician assistants, nurse midwives, and independently practicing physical and occupational therapists, excluded from the limiting charge.

    Physicians, non-physician practitioners, and suppliers must take assignment on claims for drugs and biologicals furnished on or after February 1, 2001, under §114 of the Benefits Improvement and Protection Act (BIPA).

    Effective January 1, 1993, the limiting charge is 115 percent of the fee schedule amount for nonparticipating physicians.

    EXAMPLE:

    participating fee schedule amount                $2000

    Nonparticipating fee schedule amount           $1900 (95% of $200

    Limiting charge                    $2185 ($1900 times 1.15)


    Charges to either a payer for whom Medicare is secondary or to a payer under the indirect payment procedure are not subject to the limiting charge if the physician accepts the payment received as full payment (i.e., if there is no payment by the beneficiary).

    The provider may round the limiting charge to the nearest dollar if they do so consistently for all services.

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    This segment defines the end of an interchange of zero or more functional groups and interchange-related control segments.

    The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.


    Elements Size Name Input Data Remarks   

    IEA01 1/5 Number of Included Functional Groups [Submitter-specific ID number] A count of the number of functional groups included in an interchange.  

    IEA02 9 Interchange Control Number [Submitter-specific ID number] A control number assigned by the interchange sender.



    (Functional Group Header Segment) 

    This segment indicates the beginning of a functional group and to provide control information.

    The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.


    Elements Size Name Input Data Remarks   

    GS01 2 Functional Identifier Code HC Health Care Claim.  

    GS02 2/15 Application Sender’s Code [Tufts Health Plan Submitter ID] Code identifying party sending transmission.  
    GS03 2/15 Application Receiver’s Code 170558746 Code identifying party receiving transmission.  

    GS04 8 Date [Enter the date using the format YYYYMMDD; for example, January 1, 2012 would be entered as 20120101] Functional Group creation date.

    GS05 4/8 Time [Enter the time using the format HHMM; for example, 1:30 PM would be entered as 1330] Functional Group creation time. Time expressed in 24-hour clock.  

    GS06 1/9 Group Control Number/Last Control Number [Submitter-specific number] Assigned and maintained by the sender, must be identical to the associated functional group trailer, GE-02.  

    GS07 1/2 Responsible Agency Code X Accredited Standards Committee X12.  

    GS08 1/12 Version/Release/Industry Identification Code 005010X223A2 Health Care Claim for Institutional or   005010X222A1  Health Care Claim for Professional.



     GE (Functional Group Trailer Segment) 

    The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc.


    Elements Size Name Input Data Remarks   

    GE01 1/6 Number of Transaction Sets Included [Submitter-specific number] Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element.  

    GE02 1/9 Group Control Number [Submitter-specific number] Assigned number originated and maintained by the sender



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     Charges for Missed Appointments

    CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

    The amount that the physician or supplier charges for the missed appointment must apply equally to all patients (Medicare and non-Medicare), in other words, the amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients (whatever amount that may be).

    With respect to Part A providers, in most instances a hospital outpatient department can charge a beneficiary a missed appointment charge without violating its provider agreement and 42 CFR 489.22. Because 42 CFR 489.22 applies only to inpatient services, it does not restrict a hospital outpatient department from imposing charges for missed appointments by outpatients. In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.

    Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers. Charges to beneficiaries for missed appointments should not be billed to Medicare.

    If contractors receive any claims for missed appointment charges, the following reason code and MSN messages should be used to deny the claims—

    Reason Code 204: This service/equipment/drug is not covered under the patient’s current benefit plan.

    MSN messages:

    16.59 - Medicare doesn’t pay for missed appointments.

    16.59 – Medicare no paga por citas médicas a las que no se presentó.

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    The ISA is a fixed record length segment and all positions within each of the data elements are required. The first element separator defines the element separator used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange.

    The Input Data column below contains text in [bracketed italics], which indicates special input data dependent on sender, time, date, etc.


    Elements Size Name Input Data Remarks   

    ISA01 2 Authorization Information Qualifier 00 No Authorization Information Present.  

    ISA02 10 Authorization Information [Submitter-specific ID number, or ten-space placeholder] If no Authorization Information number is present, simply enter10 spaces in this field.  

    ISA03 2 Security Information Qualifier 00 No Security Information Present.  

    ISA04 10 Security Information/Password [Submitter-specific ID number, or ten-space placeholder] If no Authorization
    Information number is present, simply enter10 spaces in this field.  

    ISA05 2 Interchange ID Qualifier/Trading Partner Qualifier ZZ Mutually Agreed.  

    ISA06 15 Interchange Sender ID/ Trading Partner ID [Tufts Health Plan Submitter ID] Sender ID (Provided by Tufts
    Health Plan).  

    ISA07 2 Interchange ID Qualifier/Tufts Health Plan Qualifier 01 DUNS (Dun & Bradstreet).  

    ISA08 15 Interchange Receiver ID/Tufts Health Plan ID 170558746 Tufts Health Plan DUNS.  

    ISA09 6 Interchange Date [Enter the date using the format YYMMDD; for example, January 1, 2012 would be entered as
    120101] Date of the interchange.


    ISA10 4 Interchange Time [Enter the time using the format HHMM; for example, 1:30 PM would be entered as 1330] Time of the interchange.  

    ISA11 1 Repetition Separator The repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator.  

    ISA12 5 Interchange Control Version Number Version Number.  

    ISA13 9 Interchange Control Number/Last Control Number [Sender-specific control number] Assigned and maintained by the interchange sender, must be identical to the associated Interchange Trailer, IEA02.

    Must increment by one number at the end of the value with each file submitted within the same business day (12:00 am to 11:59 pm).  

    ISA14 1 Acknowledgement Request [Enter either 0 or 1] The 999 will be sent regardless of Input Data.  

    ISA15 1 Interchange Usage Indicator/ Acknowledgment Test Indicator [Enter either T or P] T - Test Data,   P - Production Data.



    ISA16 1 Component Element Separator (Sub-Element) [Enter any separator character, for example : or >] Used to separate component data elements within a composite data structure; must be unique.

    ASCII Value - Component element separator.

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     Change of Ownership


    When an organization having a provider agreement undergoes a change of ownership in accordance with the principles articulated in 42 CFR Part 489 and §3210 of the State Operations Manual, the agreement with the existing provider is automatically assigned to the new owner so that there is no interruption in service. However, a new agreement with updated information must subsequently be signed and a Form CMS-855A must be submitted by both the old and new owners. Only if the provider, under the change of ownership, meets the applicable requirements for approval can the agreement be executed. For FQHCs, these requirements include PHS approval.

    An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medicare program. A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention.

    A change of ownership occurs, for example, when:

    • A sole proprietor transfers title and property to another party;

    • In the case of a partnership, there is an addition, removal, or substitution of a partner unless the partners expressly agree otherwise;

    • An incorporated organization merges with an incorporated entity that is approved by the program and the latter entity is the surviving corporation. It also occurs when two or more corporate providers consolidate and the consolidation results in the creation of a new corporate entity;

    • An unincorporated organization (a sole proprietorship or partnership) becomes incorporated; or

    • The lease of all or part of an entity constitutes a change of ownership of the leased portion.

    When an organization’s agreement is terminated, whether by the entity or by CMS, no payment is available to the provider for services it furnishes to Medicare beneficiaries on or after the effective date of the termination.

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    Involuntary Terminations

    The Secretary may terminate an agreement with a provider if it is determined that the provider:

    • Is not complying fully (or substantially in the case of SNFs) with the provisions of the agreement or with the applicable provisions of title XVIII of the Act and regulations;

    • No longer meets the appropriate conditions (requirements for SNFs) of participation;

    • Has failed to supply information which is necessary to determine whether payments are due or were due and the amounts of such payments; or

    • Refuses to permit examinations of fiscal and other records, including medical records.

    The cancellation of a SNF agreement is viewed as an involuntary termination of the agreement by the Secretary for cause. Such actions involve a finding that the SNF has not satisfactorily completed its written plan providing for the correction of deficiencies with respect to one or more of the standards in the applicable requirements of participation, or that the facility has not made substantial effort and progress in correcting such deficiencies.

    A provider which is dissatisfied with the Secretary’s determination terminating its agreement is entitled to request a hearing thereon in accordance with the appeals procedures contained in 42 CFR Part 498. There is no reconsideration step before the opportunity for a hearing.



    NOTE: The involuntary termination of a hospital’s approval authorizing it to provide extended care services, i.e., to be a swing bed facility, (see Chapter 3) does not automatically result in the involuntary termination of the hospital’s agreement relating to the provision of hospital services.


    - Processing Involuntary Terminations


    When there has been a determination by the RO that an institution or agency no longer qualifies as a provider of services, the RO notifies the provider in writing that termination of its agreement has been recommended. A copy of this notification is sent to the servicing FI so that it is aware of the potential termination. However, the FI should not divulge this information.

    If CMS central office decides that termination of the agreement is appropriate, it establishes the effective date of termination, notifies the provider in writing, and notifies the RO. The RO immediately arranges for publication of the required notice to the public and sends a formal notice of termination to the FI via Form CMS-2007

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