F1

Help

From a claims entry, inquiry, or correction screen, F1 provides a narrative description of a reason code that appears on a billing transaction (used most often in the return to provider (RTP) file).

F2

Line Item Detail Info

Enables user to access line item detail information for a particular revenue code line in FISS from page 02 of the claim.

F3

Screen Exit

Exits user to previous screens.

F4

System Exit

Terminates FISS session and returns user to blank screen where 'FSS0', 'ELGA', 'ELGH', or 'Logoff' can be entered.

F5

Scroll Back

Scrolls up (backward) through a list of revenue code page.

F6

Scroll Forward

Scrolls down (forward) through a list or revenue code page.

F7

Page Back

Moves user one FISS claim page back.

F8

Page Forward

Moves user one FISS claim page forward.

F9

Save

Saves/stores claim information. (Note: FISS will only save information when the information is complete and correct.)

F10

Scroll Left

Scrolls one page to the left. Only available on the following screens:

• MAP171A, MAP171E, MAP171D, MAP 1719, MAP1772

Also retrieves claim data for an archived claim.

F11

Scroll Right

Scrolls one page to the right. Only available on the following screens:

• MAP1712, MAP1713, MAP171A, MAP171E and MAP1771

P (Processed/Paid)

Claim is approved for payment and is on the payment floor. This is also considered to be a finalized status.

R (Rejected)

Billing transaction is rejected for reasons such as:

• Medicare eligibility issue
• Billing issues
• Duplicate to a previously submitted claim

D (Denied)

Claim is denied by medical review or claim was submitted as a demand denial.

S (Suspended)

Billing transaction is temporarily paused in FISS for processing and/or Medicare staff intervention may be required. No action is required by you unless the claim is in status/location S B6001 (Additional Development Request (ADR)). Billing transactions may be suspended for about 30 days. Claims that have been selected for an ADR or for medical review may be suspended for more than 30 days. Claims with Medicare Secondary Payer (MSP) information often require Medicare staff intervention and may be suspended for more than 60 days.

T (Return to Provider [RTP])

Billing transaction is waiting for correction by you in the RTP file.

I (Inactivated)

Billing transaction was inactivated or suppressed from RTP. Awaiting final system purge.

P B9996

Payment floor

P B9997

Processed or paid (full or partial) billing transaction

P B7501

Post-pay MSP review

P B7505

Post-pay MSP review

P O9998

Archived claim

R B9997

Rejected billing transaction (finalized)

R B75XX

Rejected billing transaction (suspended). It may take at least 75 days for the claim to move to R B9997 finalized status/location.

D B9997

Denied claim (all services denied).

Claims with partial denials will appear in the P status.

T B9900

Billing transaction will need correction when it moves into T B9997 in next cycle.

T B9997

Billing transaction needing correction by provider (referred to as the Return to Provider (RTP) status/location).

S B0100

System processing (billing transaction is suspended).

S B6000

Claim will need additional information when it moves to S B6001.

S B6001

Claim needs additional information from provider (often referred to as ADR, MR ADR (medical review Additional Development Request) or non-MR ADR).

S M50MR

Medical review of documentation (claims move to this location once ADR information has been received). This review process may take up to 60 days to complete.

S M5CLM

After the ADR documentation has been reviewed by the Medical Review department, the claim is moved to S M5CLM for additional processing.

S B90XX

Claim data is being compared with beneficiary eligibility information posted at the Common Working File (CWF).

S MXXXX

Suspended claim/adjustment requires Medicare staff intervention and may be suspended for about 30 days. Claims with Medicare Secondary Payer (MSP) information may be suspended for more than 60 days. Providers may call the Provider Contact Center if their claims have been in the same "S M XXXX " status/location for longer than 30 days, or 60 days for MSP claims.

S M87DR

Hospice Only – acknowledgement that CGS has received the documentation for an exception request for an untimely notice of election. Refer to the "Requesting an Exception for an Untimely NOE" Web page for additional information.

S M87RE

Hospice Only – the documentation provided in the Remarks field for an exception request for an untimely notice of election is being reviewed.

S M8877

Hospice Only – if documentation for an exception request for an untimely notice of election is not received within 30 days of the initial request, the claim will move to this status/location until day 45, or until your documentation is received. If documentation is not received by day 46, the claim will be released to process as billed. Refer to the "Requesting an Exception for an Untimely NOE" Web page for additional information.

S MRADJ

MSP adjustment – created after MSP adjustment received; awaiting completion.

I B9900

Billing transaction inactivated from RTP file; waiting to purge from FISS.

ID CD

The Plan Identification Code for a beneficiary who is enrolled in a Medicare Advantage (MA) Plan. The structure of the code is:

OPT CD

The current Plan services are restricted or unrestricted. The valid values are:

Unrestricted

1 – Medicare contractor to process all Part A and B provider claims
2 – Plan to process claims for directly provided service and for services from providers with effective arrangements. 

Restricted

A – Medicare contractor to process all Part A and B provider claims
B – Plan to process claims only for directly provided services
C – Plan to process all claims

The reason for the inquiry. Valid values:

1 – Status inquiry
2 – Inquiry related to an admission

The code assigned when the request is processed through the CWF host site. Valid values:

01 – Part A inquiry approved; beneficiary have 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 CMSs records, this inquiry begins a new benefit period.

CLAIM

Identifies the beneficiary's Medicare ID number

NAME

The name of the beneficiary

DOB

The date of birth of the beneficiary

SEX

The sex of the beneficiary (F – female; M – male)

INTER

The intermediary number for the provider

APP DT

Applicable Date – used for spell determination, i.e., admission date, and current date.

REASON CD

The reason for the inquiry. Valid values:

1 – Status inquiry
2 – Inquiry related to an admission

DATE/TIME

The date and time stamp

REQ ID

Identifies the individual who submitted the inquiry.

DISP CD

The code assigned when the request is processed through the CWF host site. Valid values:

01 – Part A inquiry approved; beneficiary have 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 CMSs records, this inquiry begins a new benefit period.

TYPE

Identifies the type of CWF reply. (3 – accepted)

ERROR MESSAGE:

Identifies the error message.

CLAIM

Identifies the beneficiary's Medicare ID number

NAME

The name of the beneficiary

DOB

The date of birth of the beneficiary

SEX

The sex of the beneficiary (F – female; M – male)

INTER

The intermediary number for the provider

APP DT

Applicable Date – used for spell determination, i.e., admission date, and current date.

REASON CD

The reason for the inquiry. Valid values:

1 – Status inquiry
2 – Inquiry related to an admission

DATE/TIME

The date and time stamp

REQ ID

Identifies the individual who submitted the inquiry.

DISP CD

The code assigned when the request is processed through the CWF host site. Valid values:

01 – Part A inquiry approved; beneficiary have 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 CMSs records, this inquiry begins a new benefit period.

TYPE

Identifies the type of CWF reply. (3 – accepted)

CENT D.O.B

Century Code for Date of Birth – The beneficiary/patients date of birth. This is a one-position alphanumeric field. The valid values are: This field is not used by FISS.
Value – Description:

• 8 – 18th Century
• 9 – 19th Century

D.O.D

Date of Death – The date of death of the beneficiary/patient.

A CURR ENT DT

Part A Current Entitlement Date – The current Part A entitlement date.

TERM DT

Part A Termination Date – The termination date of the current entitlement.

PRI-ENT DT

Part A Prior Entitlement Date – The prior Part A entitlement.

TERM DT

Part A Prior Termination Date – The termination date of the prior Part A entitlement.

B CURR-ENT DT

Part B Current Entitlement Date – The current Part B entitlement date.

TERM DT

Part B Termination Date – The termination date of the current entitlement.

B: CURR-ENT DT

Part B Prior Entitlement Date – The prior Part B entitlement date.

TERM DT

Part B Prior Termination Date – The termination date of the prior Part B entitlement.

PRE-ENT DT

Lifetime Reserve Days – The number of lifetime reserve days remaining.

TERM DT

Part A Termination Date – The termination date of the current entitlement.

LIFE: RSRV

Part A Prior Entitlement Date – The prior Part A entitlement.

PYSCH

Psychiatric Days Remaining – The number of lifetime psychiatric days remaining.

CURRENT BENEFIT PERIOD DATA

FRST BILL DT

First Bill Date – The earliest billing action in the current benefit period.

LST BILL DT

Last Bill Date – The date of the latest billing action in the current benefit period.

HSP FULL DAYS

Hospital Full Days – The number of regular hospital full days the remaining in the current benefit period.

HSP PART DAYS

Hospital Coinsurance Days – The number of hospital coinsurance days remaining in the current benefit period.

SNF FULL DAYS

Skilled Nursing Facility Full Days – The number of SNF full days remaining in the current benefit period.

SNF PART DAYS

Skilled Nursing Facility Coinsurance Days – The number of SNF coinsurance days remaining in the current period.

INP DED REMAIN

Inpatient Deductible Amount Remaining – The amount of inpatient deductible amount remaining to be met for the benefit period.

BLD DED PNTS

Blood Deductible Pints – The number of blood deductible pints remaining to be met for the benefit period.

PRIOR BENEFIT PERIOD DATA

FRST BILL DT

First Bill Date – This field identifies the date of the earliest billing action in the prior benefit period.

LST BILL DT

Last Bill Date – This field identifies the date of the latest billing action in the prior benefit period.

HSP FULL DAYS

Hospital Full Days – The number of regular hospital full days remaining in the prior benefit period.

HSP PART DAYS

Hospital Coinsurance Days – The number of hospital coinsurance days remaining in the prior benefit period.

SNF FULL DAYS

Skilled Nursing Facility Full Days – The number of SNF full days remaining in the prior benefit period.

SNF PART DAYS

Skilled Nursing Facility Coinsurance Days – The number of SNF coinsurance days remaining in the prior period.

INP DED REMAIN

Inpatient Deductible Amount Remaining – The amount of inpatient deductible amount remaining to be met for the benefit period.

BLD DED PNTS

Blood Deductible Pints – The number of blood deductible pints remaining for the benefit period.

CURR B: YR

Most Recent Part B Year – The most recent Medicare Part B benefit year.

CASH

Medicare Part B Cash Deductible Remaining to be Met – The amount of cash deductible remaining for the most recent Part B year.

BLOOD

Medicare Part B Blood Deductible Remaining to be Met -The amount of blood deductible pints remaining for the most recent Part B year.

PSYCH

Medicare Part B Psychiatric Limit Remaining – The Part B psychiatric limit remaining for the benefit year.

PT

Medicare Part B Physical Therapy Limit. – The Part B physical therapy limit amount applied year to date for the most recent Medicare Part B benefit year.

OT

Medicare Part B Occupational Therapy Limit – The Part B occupational therapy limit amount applied year to date for the most recent Medicare Part B benefit year.

PRIR B: YR

Prior Part B Year – The prior Medicare Part B benefit year.

CASH

Medicare Part B Cash Deductible Remaining to be Met – The amount of cash deductible remaining to be met for the prior Part B benefit year.

BLOOD

Medicare Part B Blood Deductible Remaining to be Met – The amount of blood deductible remaining to be met for the prior Part B benefit year.

PSYCH

Medicare Part B Psychiatric Limit Remaining – The Part B psychiatric limit remaining for the prior Part B benefit year.

PT

Medicare Part B Physical Therapy Limit – The Part B physical therapy limit amount applied year to date for the prior Part B benefit year.

OT

Medicare Part B Occupational Therapy Limit – The Part B occupational therapy limit amount applied year to date for the prior Part B benefit year.

DATA IND

Data Indicators – This field identifies the data indicator. Valid values for each position are:

Position 1: Part B Buy In

• 0 – Does not apply
• 1 – State buy-in involved

Position 2: Alien Indicator

• 0 – Does not apply
• 1 – Alien non-payment, provision may apply

Position 3: Psychiatric Pre-Entitlement

• 0 – Does not apply
• 1 – Psychiatric pre-entitlement reduction applied

Position 4: Reason For Entitlement

• 0 – Normal entitlement
• 1 – Disability
• 2 – End stage renal disease (ESRD)
• 3 – Has or had ESRD, but current DIB
• 4 – Old age but has or had ESRD
• 8 – Has or had ESRD and is covered under Part A premium
• 9 – Covered under Part A premium

Position 5: Part A Buy-In

• 0 – No Part A buy-in
• 1 – Part A buy-in applies

Position 6: Rep Payee Indicator

• 0 – Does not apply
• 1 – Selected for GEP contract
• 2 – Has Rep Payee
• 3 – Both conditions apply

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

NAME

The full name of the beneficiary in last name, first name, middle initial format.

ZIP

The ZIP code of residence of the beneficiary.

PLAN: ENR CD

The number of periods of Plan enrollment code. The valid values are: 0, 1, 2, and 3 indicating 0, 1, 2, or more than two periods of enrollment.

CURRENT PLAN

CUR ID

The Current Plan identification code.

OPT

The Plan Option Code – This field identifies whether the current Plan services are restricted or unrestricted.

Unrestricted

1 – Medicare contractor to process all Part A and B provider claims
2 – Plan to process claims for directly provided service and for services from providers with effective arrangements.

Restricted

A – Medicare contractor to process all Part A and B provider claims
B – Plan to process claims only for directly provided services
C – Plan to process all claims

ENR

The effective date of the current entitlement.

TERM

The termination date of the current enrollment.

PRIOR PLAN

PRI ID

The prior Plan identification code.

OPT

The prior Plan Option code.

Unrestricted

1 – Medicare contractor to process all Part A and B provider claims
2 – Plan to process claims for directly provided service and for services from providers with effective arrangements.

Restricted

A – Medicare contractor to process all Part A and B provider claims
B – Plan to process claims only for directly provided services
C – Plan to process all claims

ENR

The effective date of the prior HMO entitlement.

TERM

The termination date of the prior HMO enrollment.

OTHER ENTITLEMENTS OCCURRENCE CD

The first two occurrence codes and dates indicating another federal program or other type of insurance that may be a primary payer. The valid values are:

Value – Description:

• 1 – Workers Compensation coverage.
• 2 – Black Lung.
• A – Working Aged beneficiary or spouse covered by employer health plan.
• B – End stage renal disease (ESRD) beneficiary in his 12 month coordination period and covered by an employer health plan.
• C – Medicare has made a conditional payment pending final resolution.
• D – Automobile no-fault or other liability insurance involvement.
• E – Workers Compensation and/or Black Lung.
• F – Veterans Administration program, public health service or other federal agency program.
• G – Working disabled beneficiary or spouse covered by employer health plan.
• H – Black Lung.
• I – Veterans Administration program.

ESRD CD

The home dialysis method selection code. The valid codes are:

• 1 – The beneficiary elects to receive all supplies and equipment for home dialysis from an ESRD facility and the facility submits claims for services it renders.
• 2 – The beneficiary elects to deal directly with one supplier for home dialysis supplies and equipment and the beneficiary is responsible for submitting his/her own claims to the Carrier for reimbursement.

ESRD DATE

The home dialysis method selection effective date.

ESRD CD

The home dialysis method selection code. The valid codes are:

• 1 – The beneficiary elects to receive all supplies and equipment for home dialysis from an ESRD facility and the facility submits claims for services it renders.
• 2 – The beneficiary elects to deal directly with one supplier for home dialysis supplies and equipment and the beneficiary is responsible for submitting his/her own claims to the Carrier for reimbursement.

ESRD DATE

The home dialysis method selection effective date.

PSYCH

The the number of lifetime psychiatric days remaining for the beneficiary/patient.

DISCHG

The last or through discharge date.

IND

This field identifies whether or not the discharge date is an interim date. The valid values are:

• 0 – Initialized
• 1 – Interim

DAYS USED

The number of pre-entitled psychiatric days used by the beneficiary/patient.

BLOOD

The number of blood pints carried over from 1988 to 1989.

YR

The catastrophic trailer year.

APP

This field identifies whether a December inpatient stay has been applied to the current year deductible.

MET

The amount of inpatient hospital deductible to be met according to the catastrophic trailer year.

BLD

The number of blood deductible pints remaining to be met.

CO

The number of co-insurance SNF days remaining.

FL

The number of full SNF days remaining.

FRM

The from date of the earliest processed bill.

TO

The through date of the earliest processed bill.

IND

The yearly data indicator. This is a one-position alphanumeric field. This field provides the following information:
Position 1

• 0 – Not used
• 2 – Clerical involvement
• 3 – Religious Non-Medical Healthcare Institution/SNF usage
• 4 – Both 1 and 2

Position 2

Value – Description:

• 0 – Not used
• 1 – Through date is interim

INT

The intermediary number for the earliest hospital bill processed with a deductible.

ADM

The admission date for the earliest hospital bill processed with a deductible.

FROM

The from date for the earliest hospital bill processed with a deductible.

TO

The through date for the earliest hospital bill processed with a deductible.

APP

The deductible amount applied for the earliest hospital bill processed with a deductible.

ADJ IND

The type of adjustment made. The valid values are:

• 0 – No adjustment
• 1 – Downward adjustment
• 2 – Upward adjustment

CALC DED

The amount of deductible calculated.

CMS DATE

The date the claim was processed by CMS.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary/patient.

IT

The first initial of the beneficiary/patient name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

• F – Female
• M – Male

MAMMO RSK

Mammography Risk Indicator – This field identifies whether or not the beneficiary is at risk. The valid values are:

• Y – Yes
• N – No

TECHCOM

The date of mammography screening interpreted by a technician. Up to three technical component dates may be displayed.

PROCOM

The date of mammography screening requiring interpretation by a physician. Up to three professional component dates may be displayed.

COV IND

This field identifies whether or not the transplant was a covered procedure. Up to three coverage indicators may be displayed. The valid values are:

• N – Non-covered transplant.
• Y – Covered transplant.

TRAN IND

Transplant Indicator – This field identifies the type of transplant performed. Up to three transplant indicators may be displayed. The valid values are:

• 1 – Allogeneous bone marrow
• 2 – Autologous bone marrow
• B – Lung Transplant
• C – Heart and Lung Transplant
• D – Kidney and Pancreas Transplant
• H – Heart transplant
• I – Intestinal Transplant
• K – Kidney transplant
• L – Liver transplant
• P – Pancreas Transplant

DIS DATE

The date of discharge for the beneficiary/patient for the transplant procedure.

EPISODE START

The start date of an episode.

EPISODE END

The end date of an episode.

DOEBA

The first service date of the HHPPS period.

DOLBA

The last service date of the HHPPS period.

The specific Hospice Election Period. This is a one-position alphanumeric field with two occurences. The valid values are:

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

CLAIM

The beneficiary's Medicare ID number.

NAME

The first initial and last name of the beneficiary.

DOB

The date of birth of the beneficiary.

SEX

The sex of the beneficiary. The valid values are:

• F – Female
• M – Male

INTER

The intermediary number for the provider.

APP DT

Applicable Date – This field is used for spell determination, i.e., admission date, and current date.

REASON CD

The reason for the inquiry. The valid values are:

• 1 – Status inquiry
• 2 – Inquiry related to an admission

DATE/TIME

Date and Time Stamp (Julian).

REQ ID

The individual who submitted the inquiry.

DISP CD

CWF Disposition Code – This field identifies a code assigned when the request is processed through the CWF host site.

TYPE

The type of CWF reply. The valid values are:

• 4 – Not in file

DATE TRANSFER INITIATED TO CMS

The date the transfer was initiated to CMS.

DATE CMS INDICATED NIF/AT OTHER SITE

The date CMS indicated the beneficiary Medicare number was not in file at another site.

CLAIM

The beneficiary's Medicare ID number.

NO TITLE

The middle initial of the beneficiary.

NAME

The first initial and last name of the beneficiary.

DOB

The date of birth of the beneficiary.

SEX

The sex of the beneficiary. The valid values are:

• F – Female
• M – Male

INTER

The intermediary number for the provider.

APP DT

Applicable Date – This field is used for spell determination, i.e., admission date, and current date.

REASON CD

The reason for the inquiry. The valid values are:

• 1 – Status inquiry
• 2 – Inquiry related to an admission

DATE/TIME

Date and Time Stamp (Julian).

REQ ID

The individual who submitted the inquiry.

DISP CD

A code assigned when the request is processed through the CWF host site.

TYPE

The type of CWF reply. The valid values are:

• 5 – Not in file on CMS batch but is another potential claim number for this beneficiary.

CORRECTED CLAIM NUMBER

The corrected Medicare ID number.

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 ST DATE

The start date of the beneficiary's effective period with the Hospice provider.

PROV

The identification number assigned by Medicare to the Hospice provider.

INTER

The intermediary number of the Hospice provider.

OWNER CHANGE ST DATE

The new owner of the Hospice provider if a change of ownership occurs within an election period.

PROV

The identification number assigned by Medicare to the Hospice provider.

INTER

The intermediary number of the Hospice provider.

2NDT ST DATE

The start date of the beneficiary's effective period with the Hospice provider.

PROV

The identification number assigned by Medicare to the Hospice provider.

INTER

The intermediary number of the Hospice provider.

TERM DATE

The ending date of a beneficiary's election period.

OWNER CHANGE ST DATE

The new owner of the Hospice provider if a change of ownership occurs within an election period.

PROV

The identification number assigned by Medicare to the Hospice provider.

INTER

The intermediary number of the Hospice provider.

1ST BILLED DATE

The first billed date of the beneficiary's effective period with the Hospice provider.

LAST BILLED DATE

The last billed date of the beneficiary's effective period with the Hospice provider.

DAYS BILLED

The number of hospice days billed to date for a particular beneficiary/patient.

REVO IND

The revocation indicator.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first Initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

• F – Female
• M – Male

INT

The intermediary number for the earliest hospital bill processed with a deductible.

APP

This field identifies spell determination, i.e. admission date and current date.

REAS

The reason for the inquiry. The valid values are:

• 1 – Status inquiry
• 2 – Inquiry related to an admission

DATETIME

The date and time stamp of the inquiry.

REQ

The operator ID of the person submitting the inquiry.

DISP-CODE

The code assigned when the request is processed through the CWF host site.

MSG

The process of the episode (i.e. paid, suspended, RTP, etc.)

CORRECT

The crossover reference of a Medicare ID number and populates the correct Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

• F – Female
• M – Male

A-ENT

The current Part A entitlement.

A-TRM

The Part A termination date of the current entitlement.

B-ENT

The current Part B entitlement.

B-TRM

The Part B termination date of the current entitlement.

DOD

The date of death of the beneficiary.

PARTB YR

The most recent Medicare Part B benefit year.

DED-TBM

The Part B deductible amount.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

SPELL NUM

The spell number, up to 14 episodes.

QUALIFYING IND

The beneficiary qualified for Part A or Part B Medicare.

PARTA VISITS REMAINING

This field identifies how many visits are remaining for the beneficiary/patient.

EARLIST BILLING

The earliest date of an episode.

LATEST BILLING

The latest date of an episode.

PARTB VISITS APPLIED

This field identifies how many Part B visits were applied to the episode.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

START DATE

The start date of an episode.

END DATE

The end date of an episode.

INTER NUM

The Hospice provider intermediary number.

PROV NUM

The identification number assigned by Medicare to the Hospice provider.

DOEBA

The first service date of the HHPPS period.

DOLBA

The last service date of the HHPPS period.

PATIENT STAT ID

The patient status during the episode.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

REC

The sequence record number of the paid claims starting with 00 and occurs up to 16 times.

MSP

This field identifies MSP source.

DESCRIPTION

The value in the MSP code field. The valid values are:

• 1 – MEDICAID
• 2 – BLUE CROSS
• 3 – OTHER
• 4 – NONE
• A – WORKING AGED
• B – ESRD BENE
• C – COND PAYMENT
• D – NO-FAULT
• E – WORKERS COMP
• F – PUB HLTH SRV
• G – DISABLED
• H – BLACK LUNG
• I – VETERANS
• L – LIABILITY
• W – WC SET-ASIDE
• Z – MEDICARE

EFF DTE

The effective date of the Medicare Secondary Payer (MSP) coverage.

TRM DTE

The termination date of the Medicare Secondary Payer (MSP) coverage termination.

INTER

The Hospice provider intermediary number.

DOA

The date the entry was added.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

PLAN TYPE

This field identifies the type of plan.

PLAN ID

The Plan Identification code. The structure of the identification number is:

• Position 1 – H
• Position 2 & 3 – State Code
• Position 4 & 5 – Plan number within the state

OPT

The current Plan services are restricted or unrestricted. The valid values are:

Unrestricted

• 1 – Medicare contractor to process all Part A and B provider claims
• 2 – Plan to process claims for directly provided service and for services from providers with effective arrangements.

Restricted

• A – Medicare contractor to process all Part A and B provider claims
• B – Plan to process claims only for directly provided services
• C – Plan to process all claims

ENR DATE

The enrollment date of the Plan for a beneficiary Plan entitlement.

TRM DATE

The termination date of the Plan for a beneficiary Plan entitlement.

CN

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

PERIOD

The 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.
3 – The third time a beneficiary uses Hospice benefits.
4 – The fourth time a beneficiary uses Hospice benefits.

START DATE 1

The start date of the beneficiary's first election period with the Hospice provider.

OWNER CHANGE

The date of the Hospice provider change of ownership within an election period.

TERM DATE 1

The ending date of the beneficiary's first election period.

PROV 1

The first Hospice provider identification number assigned by Medicare.

INTER 1

The intermediary number of the first Hospice provider.

DOEBA DATE

The first service date of the HHPPS period.

DOLBA DATE

The last service date of the HHPPS period.

DAYS USED

The number of days used by the beneficiary/patient.

START DATE 2

The start date of the beneficiary's second election period with the Hospice provider.

OWNER CHANGE

The date of the Hospice provider change of ownership within an election period.

PROV 2

The second Hospice provider identification number assigned by Medicare.

INTER 2

The intermediary number of the second Hospice provider.

REVOCATION IND

The revocation indicator number.

MID

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

TECH D

Technical Date – This field identifies the date the beneficiary is eligible for preventative service coverage.

NOTE: When there is not a date, one of the following messages display to explain why the beneficiary is not eligible.

• PTB – Beneficiary not entitled to Part B
• RCVD – Beneficiary already received service
• DOD – Beneficiary not eligible due to DOD
• GDR – Beneficiary not eligible due to gender
• AGE – Beneficiary not eligible due to age
• SRV – Beneficiary not eligible for the service
• VAC – Beneficiary already vaccinated
• 0000 – Service not applicable

PROF D

Professional Date – This field identifies the date the beneficiary is eligible for preventative service coverage.

NOTE: When there is not a date, one of the following messages display to explain why the beneficiary is not eligible.

• PTB – Beneficiary not entitled to Part B
• RCVD – Beneficiary already received service
• DOD – Beneficiary not eligible due to DOD
• GDR – Beneficiary not eligible due to gender
• AGE – Beneficiary not eligible due to age
• SRV – Beneficiary not eligible for the service
• VAC – Beneficiary already vaccinated
• 0000 – Service not applicable

MID

The beneficiary's Medicare ID number.

LN

The last name of the beneficiary.

FI

The first initial of the beneficiary name.

DOB

The date of birth of the beneficiary.

SEX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

TOTAL SESSIONS

Total Sessions – This field identifies the number of sessions billed for each beneficiary. This occurs five times 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 not identified, CWF posts the session as 1 unit. (i.e., 10/25 – 10/27 Unit 1 will post as 1 session).

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

HCPCS

The HCPC code of G0375 or G0376.

FROM

The from date of the claim.

THRU

The through date of the claim.

PER

Period – This field identifies up to five years of counseling data. The valid values are:

• 1 – One year
• 2 – Two years
• 3 – Three years
• 4 – Four years
• 5 – Five years

QT

Quantity – This field identifies the number of services billed for each date.

TP

The claim type. The valid values are:

• O – Outpatient
• B – Part B

PRF

The technicaland professional remaining sessions.

MID

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

TECH D

The date the beneficiary is eligible for preventative service coverage.

Note: When there is not a date, one of the following messages display to explain why the beneficiary is not eligible.

• PTB – Beneficiary not entitled to Part B
• RCVD – Beneficiary already received service
• DOD – Beneficiary not eligible due to DOD
• GDR – Beneficiary not eligible due to gender
• AGE – Beneficiary not eligible due to age
• SRV – Beneficiary not eligible for the service
• VAC – Beneficiary already vaccinated
• 0000 – Service not applicable

PROF D

The date the beneficiary is eligible for preventative service coverage.

Note: When there is not a date, one of the following messages display to explain why the beneficiary is not eligible.

• PTB – Beneficiary not entitled to Part B
• RCVD – Beneficiary already received service
• DOD – Beneficiary not eligible due to DOD
• GDR – Beneficiary not eligible due to gender
• AGE – Beneficiary not eligible due to age
• SRV – Beneficiary not eligible for the service
• 0000 – Service not applicable

MID

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

HCPC CODE

The HCPC code.

TECH CODE

This field identifies the technical code.

RISK CD

The breast cancer risk indicator for the beneficiary. The valid values are:

• Y – High Risk
• N – Not High Risk

DATE

Date 1 – This field identifies the date the HCPC code was returned from CWF.

DATE

Date 2 – This field identifies the date the TECH code was returned from CWF.

DATE

Date 3 – This field identifies the date the RISK code was returned from CWF.

MID

The beneficiary's Medicare ID number.

NM

The last name of the beneficiary.

IT

The first initial of the beneficiary name.

DB

The date of birth of the beneficiary.

SX

The sex of the beneficiary. The valid values are:

F – Female

M – Male

PROVIDER NUMBER

The identification number assigned by Medicare to the Hospice provider.

START DATE

The beginning date of a beneficiary's election of the MCCM Hospice provider.

TERM DATE

The ending date of a beneficiary's election of the MCCM Hospice provider.

TRANSFER DATE

The date of the MCCM Hospice provider change of ownership.

The sex of the beneficiary. The valid values are:

F – Female

M – Male

The sex of the beneficiary. The valid values are:

F – Female

M – Male

The sex of the beneficiary. The valid values are:

F – Female

M – Male

DIAGNOSIS

ICD diagnosis codes that identify up to nine codes for coexisting conditions on a particular claim. The admitting diagnosis is not entered.

No Title

This field follows the ICD diagnosis code field and identifies the Present On Admission (POA) indicator for every principal and secondary diagnosis and whether the patient's condition is present at the time the order for inpatient admission to a general acute care hospital occurs.

POA

The End of POA Indicator. This is the last character of the POA Indicator. Valid values:

X – The end of POA indicators for principal and, if applicable, other diagnoses in special processing situations that may be identified by CMS in the future.
Z – The end of POE indicators for principal and, if applicable other diagnoses.
Blank – Not acute care, POA's do not apply.

PROCEDURES

ICD procedure codes that identify the principal procedure performed and up to eight additional procedures during the billing period.

NPI

The providers National Provider Identifier (NPI) number.

SEX

The beneficiary's gender.

C – I

Century indicator – Valid values are: 8 = 1800-1899 9 = 1900-1999 2 = 2000

DISCHARGE STATUS

The beneficiary's discharge status code.

DT

The date the beneficiary was discharged (MMDDYY format).

PROV

The provider's Medicare number

REVIEW CODE

Identifies the code used to calculate the standard payment. Valid values are:

TOTAL CHARGES

The total charge as submitted on the claim.

DOB

The beneficiary's date of birth (MMDDCCYY format).

OR AGE

The beneficiary's age at the time of discharge. This field may be used instead of the DOB field.

APPROVED LOS

The approved length of stay (LOS). This is necessary for Pricer to determine whether day outlier status is applicable in non-transfer cases, and in transfer cases to determine the number of days for which to pay the per diem rate.

COV DAYS

Identifies the number of Medicare Part A days covered for this claim. Pricer uses the relationship between the covered days and the day outlier trim point of the assigned DRG to calculate the rate.

LTR DAYS

Identifies the number of Lifetime Reserve (LTR) days used for a claim.

PAT LIAB

Identifies the patient liability that is due, which is the dollar amount owed by the beneficiary to cover any coinsurance days or non-covered days or charges.

GROUPER VERSION

The version of the Grouper program used.

DRG

Identifies the Diagnosis Related Group code assigned by the grouper program.

INIT

INIT identifies the initial DRG code assigned. Used in the event a Hospital Acquired Condition (HAC) impacts the final MS-DRG assignment.

MAJOR DIAG CAT

INIT Identifies the Major Diagnostic Category in which the DRG resides. Valid values are:

RETURN CODE

Identifies the status of the claim when it has returned from the Grouper program.

PROC CD USED

Identifies the procedure code used by the Grouper program for calculation.

DIAG CD USED

Identifies the primary diagnosis code used by the Grouper program for calculation.

SEC DIAG USED

Identifies the secondary diagnosis code used by the Group program for calculation.

The capital PPS payment methodology based on the value of the PPS Pay Code. Valid values are:

The Bundled Payment for Care Improvement Indicator. Valid values are:

The Operating HSP (Hospital Specific Payment) DRG amount.

The Bundled Payment for Care Improvement Indicator. Valid values are:

The Value Based Pricing Indicator.

The Bundled Payment for Care Improvement Indicator. Valid values are:

The Value Based Pricing Adjustment.

The Bundled Payment for Care Improvement Indicator. Valid values are:

The Hospital Readmission Reduction (HRR) Program Indicator.

Reserved for future use. Valid values for IPPS.

Blank – Hospital Acquired Condition Reduction Program – Non PPS

N – Hospital Acquired Condition Reduction Program – PPS

NPC

Non-payment code. The code indicating why payment was not made.

Values are:

B Benefits exhausted
N All other reasons
R Spell of illness benefits refused, certification refused, failure to submit evidence, provider responsible for not filing timely,ro Waiver of Liability
W Workers compensation
X MSP cost avoided
Z System set for type of bills 322 – MSP Primary Payer

NOTE: this code displays on home health Requests for Anticipated Payment (RAPs) when:

• there is another insurer that is primary to Medicare.
• the "From" date of a RAP falls within a Medicare Advantage plan enrollment period.

MSP DENIAL IND

Medicare Secondary Payer Denial Indicator. Identifies to the MSPPAY module that an insurer primary to Medicare has denied this line item. The valid values are:

" " – not denied
D – denied

OCE FLAGS

Flag 1 – Service Indicator – valid values are:

B – Non-allowed item or service for OPPS
M – Medical Review changes a HIPPS code
P – Pricer upcode/downcode; The Pricer program in FISS changes the HIPPS code to "early" or "late" based on the beneficiary's adjacent episode history posted to the Common Working File (CWF) and/or the claim contains more or less therapy revenue codes than indicated by the HIPPS code submitted.

Flag 2 – Payment Indicator
Flag 3 – Discounting Formula Number
Flag 4 – Line Item Denial or Rejection Flag
Flag 5 – Packing Flag
Flag 6 – Payment Adjustment Flag
Flag 7 – Payment Method Flag
Flag 8 – Line Item Action Flag
Flag 9 – Composite Adjustment
Flag 10 – Claim Receipt Flag

MSP PAYER – 1 ID

Medicare Secondary Payer Payer-1 ID – Displays 1-position alphanumeric code identifying the specific payer. If Medicare is primary, this field will be blank. The valid values are:

1 – Medicaid
2 – Blue Cross
3 – Other
4 – None
A – Working Aged
B – ESRD beneficiary in a 30-month coordination period with an employer group health plan
C – Conditional payment
D – Auto no-fault
E – Worker's Compensation
F – Public Health Service or other Federal Agency
G – Disabled
H – Black Lung
L – Liability

MSP PAYER – 2 ID

Medicare Secondary Payer Payer-2 ID – Displays 1-position alphanumeric code identifying the specific payer. If Medicare is secondary, this field will be blank. The valid values are:

1 – Medicaid
2 – Blue Cross
3 – Other
4 – None
A – Working Aged
B – ESRD beneficiary in a 12-month coordination period with an employer group health plan
C – Conditional payment
D – Auto no-fault
E – Worker's Compensation
F – Public Health Service or other Federal Agency
G – Disabled
H – Black Lung
L – Liability

PAT REIMB

Patient Reimbursement. This field identifies the system generated calculated line amount to be paid to the patient on the basis of the amount entered by the provider on Page 03 of the claim, in the "Due From PAT" field.

PAT RESP

Patient Responsibility. Identifies the amount for which the individual receiving services is responsible. The amount is calculated as follows:

• If Payer 1 indicator is C or Z, the amount equals: cash deductible + coinsurance + blood deductible.
• If Payer 1 indicator is not C or Z, the amount equals: MSP blood + MSP cash deductible + MSP coinsurance.

PAY METHOD

Payment Method. Identifies the payment method returned from OCE.
Valid values are:
1 – paid standard OPPS amount (status indicators S, T, V, X, or P)
2 – services not paid under OPPS (status indicator A)
3 – not paid (status indicators W, Y, or E) or not paid under OPPS (status indicators B, C or Z)
4 – acquisition cost paid (status indicator F)
5 – additional payment for drug or biological (status indicator G)
6 – additional payment for device (status indicator H)
7 – additional payment for new drug or new biological (status indicator J)
9 – no additional payment included in line items with APCS (status indicator N, or no HCPCS code and certain revenue codes, or HCPCS codes Q0082 (activity therapy), G0129 (occupational therapy), or G0177 (partial hospitalization program services)

IDE/NDC/UPC

Identifies IDE, NDC, and UPC.

ASC GRP

Identifies the ASC group code for the indicated revenue code.

%

ASC Percentage. Identifies the percentage used by the ASC Pricer in its calculation for the indicated revenue code.

NONPAY CD

Non-Pay Code. Identifies the reason for Medicare's decision not to make payment. Valid values are:

GENER HARDCPY

Generate hardcopy. Instructs system to generate a specific type of hard copy document. Valid values are:

MR INCLD IN COMP

Composite Medical Review Included in Composite Rate.

CL MR IND

Complex Manual Medical Review Indicator. Identifies if all services on the claim received complex manual medical review. Valid values:
""The services did not receive manual medical review.
Y Medical records received and this service received complex manual medical review. A "Y" will display when the OCE FLAGS field on Map 171A displays an "M" (Medical Review changes a HIPPS code).
N Medical records were not received and this service received routine manual medical review.

TPE-TO-TPE

Tape to Tape flag. Displays the tape-to-tape flag indicating the system to either perform or skip a function. If the value in this field is "X", the claim data information is not posted to the Common Working File (CWF). If this field is blank, the claim data from the finalized (status/location P B9997, R B9997, or D B9997) billing transaction did post to CWF. Whenever claim data has posted to CWF, a cancel or adjustment must be submitted to remove or change this information. Valid values and the functions include:

USER ACT CODE

User Action Code. For intermediary use for medical review and reconsideration only. Valid values are:

A – pay per waiver – full technical
B – pay per waiver – full medical
C – provider liability – full medical – subject to waiver provision
D – beneficiary liability – full – subject to waiver provision
E – pay claim – line full
F – pay claim partial – claim must be updated to reflect liability
G – provider liability – full technical – subject to waiver provision
H – full/partial denial with multiple liabilities – claim must be updated to reflect liability
I – full provider liability – medical – not subject to waiver provision
J – full provider liability – technical – not subject to waiver provision
K – full beneficiary liability – not subject to waiver provision
L – full provider liability – code changed to reflect actual service
M – pay per waiver – line or partial line
N – provider liability – line or partial line
O – beneficiary liability – line or partial line
P – open biopsy changed to closed biopsy
Q – release with no medical review performed
R – CWF denied but medical review was performed
Z – force claim to be re-edited by medical policy
5 – set systematically from the reason code file to identify claims for which special processing is required
7 – force claim to be re-edited by medical policy edits in the 5XXXX range
8 – claim was suspended via an OCE MED review reason
9 – claim has been identified as a first claim review

WAIV IND

Waiver Indicator. Identifies whether the provider has their presumptive waiver status. This field is no longer used.

MR REV URC

Medical Review Utilization Review Committee Reversal.

DEMAND

Medical Review Demand Reversal

REJ CD

Reject Code. Identifies the reason code for which the claim is being denied (on full claim denials only).

MR HOSP RED

Medical Review Hospice Reduced. For hospice claims, this field identifies the line item(s) has been reduced to a lesser charge by medical review. Valid values are:

Y – Reduced
" " – Not reduced

RCN IND

Reconsideration Indicator. Only used on home health claims. Valid values are:

A – finalized count affirmed
B – finalized no adjustment count (pay per waiver)
R – finalized count reversal (adjustment)
U – reconsideration

MR HOSP RO

Medical Review Regional Office Referred. For hospice claims, if the claim has been referred to the CMS Regional Office for questionable revocation, the medical review operator will indicate so by entering a Y in this field, otherwise the field will be blank.

ORIG UAC

Original User Action Code. For intermediary use only.

MED REV RSNS

Medical Review Reasons. Identifies a specific error condition relative to medical review. There are up to nine medical review reasons that can be captured per claim. This field only displays medical review reasons specific to claim level.

OCE MED REV
RSNS

OCE Medical Review Reasons.

Unlabeled

Identifies the line number of the revenue code. The line number is located above the revenue code field on this Map. To move to another revenue code, press F6 to scroll down and F5 to scroll up.

REV

Revenue Code.

HCPC/MOD IN

HCPCS Code/Modifier. Valid values are:

U – upcoding
D – downcoding
" " – no downcoding

HCPC

Healthcare Common Procedure Coding System. Indicates 5-position HCPCS associated with the revenue code.

MODIFIERS

Healthcare Common Procedure Coding System Modifier.

SERV DATE

Service date. Line item date of service associated with the revenue code.

COV-UNT

Covered units. Reflects the number of covered visits associated with the revenue code.

COV-CHRG

Covered charges. Represents the covered charges associated with the revenue code.

ADR REASON
CODES

Additional Development Request. ADR reason codes used when additional information has been requested.

FMR REASON
CODES

Focused Medical Review Suspense Codes. Identifies the medical review suspense codes when a claim is edited based on the medical policy parameter file.

ODC REASON
CODES

Original Denial Reason Code. Identifies the original denial reason codes.

ORIG

Original HCPCS or HIPPS code, or modifiers billed.

ORIG REV
CODE

Original revenue code billed.

MR

Complex Manual Medical Review Indicator. Identifies if all services on the claim received complex manual medical review. Valid values are:

" " – services did not receive manual medical review
Y – medical records received and services received complex manual medical review
N – medical records were not received and services received routine manual medical review

OCE OVR

Override. Overrides the way the OCE module controls the line item. Valid values are:

0 – OCE line item denial or rejection is not ignored
1 – OCE line item denial or rejection is ignored
2 – External line item denial. Line item is denied even if no OCE edits.
3 – External line item reject. Line item is rejected even if no OCE edits.
4 – External line item adjustment. Technical charge rules apply.

CWF OVR

CWF Home Health Override. Overrides the way the OCE module controls the line item.

NCD OVR

National Coverage Determination Override Indicator. Identifies whether the line has been reviewed for medical necessity and should bypass the NCD edits, the line has no covered charges and should bypass the NCD edits, or the line should not bypass the NCD edits. Valid values are:

" " – NCD edits are not bypassed
Y – the line has been reviewed for medical necessity and bypasses the NCD edits
D – the line has no covered charges and bypasses the NCD edits

NCD DOC

National Coverage Determination Documentation Indicator. Identifies whether the documentation was received for the necessary medical service. Valid values are:

Y – the documentation supporting the medical necessity was received.
N – the documentation supporting the medical necessity was not received.

NCD RESP

National Coverage Determination Response Code. Identifies the response code that is returned from the NCD edits. Valid values are:

" " – default
0 – the HCPCS/diagnosis code matched the NCD edit table pass criteria. The line continues through the internal local medical necessity edits.
1 – the line continues through the internal local medical necessity edits because: the HCPCS code was not applicable to the NCD edit table process, the date of services was not within the range of the effective dates for the codes, the override indicator is set to Y or D, or the HCPCS code field is blank.
2 – none of the diagnoses supported the medical necessity of the claim, but the documentation indicator shows that the documentation to support medical necessity is provided. The line suspends for medical review.
3 – the HCPCS/diagnosis code matched the NCD edit table list ICD deny codes. The line suspends and indicates that the service is not covered and is to be denied as beneficiary liable due to noncoverage by statute.
4 – none of the diagnosis codes on the claim support the medical necessity for the procedure and no additional documentation is provided. This line suspends as not medically necessary and will be denied.
5 – diagnosis codes were not passed to the NCD edit module for the NCD HCPCS code. The claim suspends and will move to the Return to Provider (RTP) file.

NCD #

National Coverage Determination Number. This field identifies the NCD number associated with the beneficiaries claim denial. This is an eight-position alphanumeric field.

OLUAC

Original Line User Action Code. Identifies the original line user action code and is only used when there is a line user action code and a corresponding medical review denial reason code in the Benefits Savings portion of the claim.

LUAC

Line User Action Code. This is a 2-position field. The 1st position indicates the cause of the denial reason for the specific revenue line (see the USER ACT CODE field of this FISS Guide chapter for valid values). The 2nd position indicates the reconsideration code. A value equal to R indicates that reconsideration has been performed.

NON COV-UNT

Noncovered units. Contains the number of units that are being denied, if applicable.

NON COV-CHRG

Noncovered charges. Identifies the total of denied/rejected/noncovered charges for each line item being denied.

DENIAL REAS

Denial Reason. Identifies the reason code associated with the denial for the revenue code line.

OVER CODE

Override Code. Overrides the system generated ANSI codes from the denial reason code file. The valid values are:

A – override system generated ANSI code
" " – system default

ST/LC OVER

Status/location Override. Overrides the reason code file status. Only used by CGS. Valid values are:

D – denied line item for the reason code.
R – rejected the line item for the reason code
" " – processed claim with no override action

MED TEC

Medical Technical Denial Indicator. Identifies the appropriate Medical Technical Denial indicator used when performing the medical review denial of a line item. The valid values are:

A – home health only – not intermittent care – technical and waiver was applied
B – home health only – not homebound – technical and waiver was applied
C – home health only – lack of physician's orders – technical deletion and waiver was not applied
D – home health only – records not submitted after the request – technical deletion and waiver was not applied
M – medical denial and waiver was applied
S – medical denial and waiver was not applied
T – technical denial and waiver was applied
U – technical denial and waiver was not applied

ANSI ADJ

ANSI Adjustment Reason Code. Identifies the ANSI adjustment reason code associated with the denial reason for each line item.

ANSI GRP

ANSI Group Code. Contains the ANSI group code associated with the denial reason for each line item.

ANSI REMARKS

ANSI Remarks Code. Contains the ANSI remarks codes associated with the denial reason for each line item.

TOTAL

Contains the sum of all revenue code noncovered units.

LINE ITEM
REASON CODES

Identifies the reason code that is assigned for suspending the line item.

M1033-HSTRY-FALLS
OA (OASIS Assessment)

MR (Medical Review)

This field indicates if there are risk factors for hospitalization-falls. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-WEIGHT-LOSS

OA
MR

This field indicates if there are risk factors for hospitalization-weight loss. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-MLTPL HOSPZTN

OA
MR

This field indicates if there are risk factors for hospitalization-multiple hospitalizations. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-MLTPL-ED-VISIT

OA
MR

This field indicates if there are risk factors for hospitalization-multiple emergency department visits. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-MNTL-BHV-DCLN

OA
MR

This field indicates if there are risk factors for hospitalization-mental behavior decline. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-COMPLIANCE

OA
MR

This field indicates if there are risk factors for hospitalization-compliance. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-5PLUS-MDCTN

OA
MR

This field indicates if there are risk factors for hospitalization-currently taking 5 or more medications. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-CRNT-EXHSTN

OA
MR

This field indicates if there are risk factors for hospitalization-exhaustion. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-OTHER RISK

OA
MR

This field indicates if there are risk factors for hospitalization-other risks. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1033-NONE-ABOVE

OA
MR

This field indicates if there are risk factors for hospitalization-none of the above. One position numeric field.
Valid Values:
0 – Unchecked (No)
1 – Checked (Yes)
9 – No iQIES Assessment found

M1800-CRNT-GROOMING

OA
MR

This field indicates Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). Two position numeric field.
Valid Values:
00 – Able to groom self unaided, with or without the use of assistive devices or adapted methods
01 – Grooming utensils must be placed within reach before able to complete grooming activities.
02 – Someone must assist the patient to groom self.
03 – Patient depends entirely upon someone else for grooming needs.
99 – No iQIES Assessment found

M1810-DRESS-UPPER

OA
MR

This field indicates Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. Two position numeric field.
Valid Values:
00 – Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.
01 – Able to dress upper body without assistance if clothing is laid out or handed to the patient.
02 – Someone must help the patient put on upper body clothing.
03 – Patient depends entirely upon another person to dress the upper body.
99 – No iQIES Assessment found

M1820-DRESS-LOWER

OA
MR

This field indicates Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. Two position numeric field.
Valid Values:
00 – Able to obtain, put on, and remove clothing and shoes without assistance.
01 – Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.
02 – Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
03 – Patient depends entirely upon another person to dress the lower body.
99 – No iQIES Assessment found

M1830-CRNT-BATHG

OA
MR

This field indicates Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). Two position numeric field.
Valid Values:
00 – Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
01 – With the use of devised, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower.
02 – Able to bathe in shower or tube with the intermittent assistance of another person.

1. For intermittent supervision or encouragement or reminders, OR
2. To get in and out of the shower or tube, OR
3. For washing difficult to reach areas.

03 – Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.
04 – Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode.
05 – Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink in bedside chair, or on commode, with the assistance or supervision of another person.
06 – Unable to participate effectively in bathing and is bathed totally by another person.
99 – No iQIES Assessment found

M1840-CRNT TOILTG

OA
MR

This field indicates Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. Two position numeric field.
Valid Values:
00 – Able to get to and from the toilet and transfer independently with or without a device.
01 – When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.
02 – Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).
03 – Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
04 – Is totally dependent in toileting.
99 – No iQIES Assessment found

M1850-CRNT-TRNSFRNG

OA
MR

This field indicates Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast Two position numeric field.
Valid Values:
00 – Able to independently transfer.
01 – Able to transfer with minimal human assistance or with use of an assistive device.
02 – Able to bear weight and pivot during the transfer process but unable to transfer self.
03 – Unable to transfer self and is unable to bear weight or pivot when transferred to another person.
04 – Bedfast, unable to transfer but is able to turn and position slef in bed.
05 – Bedfast, unable to transfer and is unable to turn and position self.
99 – No iQIES Assessment found

M1860-CRNT-AMBLTN

OA
MR

This field indicates Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. Two position numeric field.
Valid Values:
00 – Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device).
01 – With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk or even and uneven surfaces and negotiate stairs with or without railings.
02 – Requires use of a two-handed device (for example, walker, or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.
03 – Able to walk only with the supervision or assistance of another person at all times.
04 – Chairfast, unable to ambulate but is able to wheel self independently.
05 – Chairfast, unable to ambulate and is unable to wheel self.
06 – Bedfast, unable to ambulate or be up in a chair.
99 – No iQIES Assessment found

REV CD

Revenue code. A 4-digit field that represent the type of service, supply, or equipment being provided.

EFF DT

Effective date. The date the revenue code became effective (MMDDYY format).

IND

Effective date indicator. This date instructs the system to either use the "from" date of the claim or the system run date to perform edits for this revenue code. Values are:

F Claim from date
R Claim receipt date
D Claim discharge date

TRM DT

Termination date. The date the revenue code became invalid. (MMDDYY format).

NARR

Narrative. The English-language description for the revenue code.

TOB

Type of bill. The first two digits of the type of bill followed by an 'X' denoting the frequency.

ALLOW:

Allowable. This field indicates whether the revenue code is valid for the type of bill. Values are:

Y Yes
N No

EFF-DT

Allowable effective date. The date the revenue code became a valid code (MMDDYY format).

TRM-DT

Allowable termination date. The date the revenue code was no longer valid (MMDDYY format).

HCPC:

Healthcare Common Procedure Code System. This field indicates whether the revenue code requires a HCPCS. Values are:

Y Yes
N No
V Validation of HCPCS is required

EFF-DT

HCPCS effective date. The beginning date the HCPCS code became required for this revenue code (MMDDYY format).

TRM-DT

HCPCS termination date. The date the HCPCS code was no longer required for this revenue code (MMDDYY format).

UNITS:

Units required. This field indicates whether units must be entered for this revenue code. Values are:

Y Yes
N No

EFF-DT

Unit's effective date. The beginning date units became required for this revenue code (MMDDYY format).

TRM-DT

Unit's termination date. The date units were no longer required for this revenue code (MMDDYY format).

RATE:

Rate. This field indicates whether a rate must be entered for this revenue code. Values are:

Y Yes
N No
Note: This field is currently not functional, and will always show "N".

EFF-DT

Rate's effective date. The beginning date for the requirement to enter a rate for this revenue code (MMDDYY format).

TRM-DT

Rate's termination date. The end date for the requirement to enter a rate for this revenue code (MMDDYY format).

This field identifies whether the HCPCS code is a drug. The valid values are:

E – HCPCS is a drug
" " – HCPCS is not a drug

EFF

Effective date indicator. This indicator instructs the system to either use the 'from' and 'through' dates of the claim or the system run date to perform edits for this HCPCS. Values are:

F Claim from date
R Claim receipt date
D Discharge date

OVR

Override code. This field instructs the system in applying the services towards deductible and coinsurance. Values are:

0 Apply deductible and coinsurance
1 Do not apply deductible
2 Do not apply coinsurance
3 Do not apply deductible or coinsurance
4 No need for total charges (used for multiple HCPCS for single revenue code centers)
5 Rural health clinic or comprehensive outpatient rehabilitation facility psychiatric
M Employer group health plan (EGHP) (only used on the 0001 total line for Medicare Secondary Payer (MSP))
N Non-EGHP (only used on the 0001 total line for MSP)
X Bypass cost avoided MSP edits
Y MSP cost avoided

FEE

Fee Indicator. The fee indicator received in the Physician Fee Schedule file. Valid values:
B Bundled procedure
R Rehab/Audiology Function Test/CORF Services
" " Default

OPH

Outpatient Hospital Indicator. The outpatient hospital indicator received in the physician fee schedule abstract test file. Valid values:
O Fee applicable in Hospital Outpatient Setting
1 Fee not applicable in Hospital Outpatient Setting
" " Default

CAT

Category Code. This field identifies the category of the DME equipment. The valid values are:

1 Inexpensive or other routinely purchased DME
2 DME items requiring frequent maintenance and substantial servicing
3 Certain customized DME items
4 Prosthetic and orthotic devices
5 Capped rental DME items
6 Oxygen and oxygen equipment

PC/TC

Professional Component/Technical Component. Valid values are:

0 Pay the Health Professional Shortage Area (HPSA) bonus
1 Globally billed. Professional component for this service qualifies for the HPSA bonus payment
2 Professional component only, pay the HPSA bonus
3 Technical component only, do not pay the HPSA bonus
4 Global test only. Professional component of this service qualifies for the HPSA bonus payment
5 Incident codes, do not pay the HPSA bonus
6 Laboratory physician interpretation codes, pay the HPSA bonus
7 Physical therapy service, do not pay the HPSA bonus
8 Physician interpretation codes, pay the HPSA bonus
9 Concept of PC/TC does not apply, do not pay the HPSA bonus

Claim types. The claim types identified for each adjustment reason code. The claim types are:

I Inpatient/SNF
O Outpatient
H Home Health/CORF
A All Claims

The claim types identified for each adjustment reason code. Valid claim types are:

I Inpatient/SNF
O Outpatient
H Home Health/CORF
A All Claims

REAS CODE

Reason code. The reason code identifies a specific condition assigned to the claims during processing. The following identifies the meaning of the first digit of the reason code.

CC IND

Clean claim indicator. This field instructs the system whether to pay interest. Values are:

A PIP other.
B PIP clean.
C Non-PIP other.
D Non-PIP clean.
E Additional information was requested (non-PIP).
F Additional information was requested (PIP).
G A reply was received from the Common Working File (CWF) providing a date of death, which required development in order to process the claim (non-PIP).
H A reply was received from CWF providing a date of death, which required development in order to process the claim (PIP).
I A non-definitive response was received from CWF requiring development (non-PIP).
J A non-definitive response was received from CWF requiring development (PIP).
K A definitive response was not received from CWF within 7 days (delayed response) (non-PIP).
L A definitive response was not received from CWF within 7 days (delayed response) (PIP).
M The claim was manually set to non-clean. This will only occur in rare situations such as a claim requiring development external to the intermediary's operation (non-PIP).
N The claim was manually set to non-clean. This will only occur in rare situations such as a claim requiring development external to the intermediary's operation (PIP).
O The claim is a sequential claim in which the prior claim was pending (non-PIP).
P The claim is a sequential claim in which the prior claim was pending (PIP).

FISS DCN

Enter the FISS document control number (DCN) of the claim to populate the Invoice Number field. Up to five DCNs can be entered.

INVOICE NUMBER

Enter the HIGLAS invoice number to populate the FISS DCN field. Up to five DCNs can be entered.

Identifies the rural indicator. Valid values are:

U – Urban
R – Rural
B – Rural Bonus

Identifies the rural indicator. Valid values are:

U – Urban
R – Rural
B – Rural Bonus

Identifies the ASP price bucket indicator. Valid values are:

A through Z with the exception of H, I, O, R, S = ASP price bucket indicators

Identifies the plus 4 flag indicator. Valid values are:

0 – No +4 Extnesion
1 – +4 Extension

The Category field identifies different items within the list. Valid values are:

## – First two digits of the type of bill, e.g., 11, 13, 32, 34, 72, 74, 81, 82.
GT – Grand total of claims currently in process.
TC – Total count of claims in a particular status/location.
AD – An adjustment
NM – Non-medical indicates the claim was placed in RTP because of a clerical error.
MP – Medical policy indicates the claim was placed in RTP because of nonclerical error.

The record type for the ANSI standard code. Valid values are:

A Appeals
C Adjustment Reasons
G Groups
R Reference Remarks
S Claim Status
T Claim Category