Corporate

Claim Page 01 – Correcting a Notice of Election (NOE)

For notices of election (NOEs) with the “From” date on or after January 1, 2018, review the following information for correcting a NOE date using the Fiscal Intermediary Standard System (FISS) Claims/Attachments option (FISS Main Menu option 02) via Direct Data Entry (DDE). NOEs may also be submitted via Electronic Data Interchange (EDI) effective with the January 2, 2018, implementation of Change Request (CR) 10064External PDF. Refer to CMS 837I NOE Companion GuideExternal PDF for the required elements. 

Claim Page 01 (Map 1711) contains general patient information, condition codes, occurrence codes, occurrence span codes and value codes.

Begin entering data on Claim Page 01 and continue until the necessary fields are completed. Use the key and table below to determine what fields are required and what information to enter.

Note: The codes listed on this page represent those most frequently submitted on hospice claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website.

Screen Shot

Key:

  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, dependent on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field

Field Descriptions for Claim Page 01 – Map 1711

Field Name/Requirement

Description

MID
Required

Enter the beneficiary's Medicare ID number

TOB
Required

Type of bill (system generated). FISS Page 01 defaults the type of bill (TOB) to 81A. You may need to change this depending on the TOB you are entering.

81A - Freestanding hospice
82A - Hospital based hospice

NPI
Required

Enter your National Provider Identifier.

PAT.CNTL#
Optional

Up to 20 digits are available for you to enter your internal account number for tracking purposes. This number will display on your Remittance Advice or your Electronic Remittance Advice

STMT DATES FROM
Required

Enter the correct effective date of this hospice election in MMDDYY format.

The date must match the ADMIT DATE and the date reported with Occurrence Code 27.

LAST
Required

Enter the beneficiary's last name exactly as it appears on the beneficiary's eligibility file, including any spaces, apostrophes, hyphens or suffixes.

FIRST
Required

Enter the beneficiary's first name exactly as it appears on the beneficiary's eligibility file.

MI
Optional

Enter the beneficiary's middle initial.

DOB
Required

Enter the beneficiary's date of birth.

ADDR 1-6
Required

Enter the beneficiary's full mailing address, including street name and number, post office box number or RFD, city and state.

ZIP
Required

Enter the beneficiary's 5- or 9- digit zip code.

SEX
Required

Enter the beneficiary's gender using the appropriate alpha character.

M = Male F= Female

MS
Optional

Beneficiary's marital status

ADMIT DATE
Required

Enter the correct effective date of the hospice election.

COND CODES
Required

Effective for NOEs with the “From” date on or after January 1, 2018.

Enter D0 (zero).

Note: When D0 is entered, Occurrence Code 56 and date must also be submitted.

OCC CDS/DATE
Required

Occurrence code 27 – Enter the correct date of certification. This date must match what is entered in the FROM date and ADMIT DATE.

Occurrence code 56 - Enter the incorrect date of certification (the date submitted on the original NOE). Effective for NOEs with the “From” date on or after January 1, 2018.

FAC.ZIP
Required

Facility zip code of the provider or the subpart (9-digit).

Refer to the Claim Page 03 – Entering a Notice of Election (NOE) or Transfer NOE for the remaining data elements that need to be submitted when correcting an NOE.

Additional FISS Claim Pages

Updated: 09.28.18

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