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Claim Page 01 – Correcting a Notice of Termination/Revocation - NOTR (8XB)

For notices of termination/revocation (NOTRs) with the "From" date on or after January 1, 2018, review the following for correcting an NOTR date using the Fiscal Intermediary Standard System (FISS) Claim/Attachments option.

An NOTR may be submitted to CGS via direct data entry (DDE), meaning it can be keyed directly into the Fiscal Intermediary Standard System (FISS). To submit a NOTR, providers may use FISS Option 49 (NOE/NOA), and complete information on Claim Page 01 and Claim Page 03. You may also submit NOEs 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. Additional information is also available in the following Medicare Learning Network (MLN®) Matters articles.

The screenprints and tables below indicate what fields are required, and what data is required in each field.

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 NOTR Page 01 – MAP 1711

Field Name/Requirement

Description

MID
Required

Enter the beneficiary's Medicare ID number

TOB
Required

81B (nonhospital based)

82B (Hospital-based)

NPI
Required

Enter your National Provider Identifier (NPI)

PAT. CNTL#
Optional

Up to 20 digits are available for you to enter your internal account number for tracking purposes.

STMT DATES FROM/TO
Required

FROM – Enter the start date of the hospice benefit period in which the discharge/revocation is effective.

Example: The benefit period in which the discharge/revocation occurred is 04/16/YY to 06/14/YY. The revocation was effective 05/31/YY. The FROM date reported would be 04/16/YY.

Note: If the beneficiary transferred to your hospice during the benefit period, the FROM date should reflect the date of transfer.

TO – Enter the correct date the discharge/revocation is effective.

NOTE: If the original NOTR was submitted entirely in error, enter zeros as the “TO” date. Zeros in the “TO” date field is only allowed in DDE.

LAST
Required

Enter the beneficiary's last name exactly as it appears on the Medicare card or the beneficiary's eligibility file.

FIRST
Required

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

DOB
Required

Enter the beneficiary's date of birth.

ADDR
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 zip code.

SEX
Required

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

M= Male F=Female

ADMIT DATE
Required

Enter the start date of the hospice election period in which the discharge or revocation is effective. This date should match the “FROM” date submitted on the NOE, TOB 8XA if the beneficiary did not transfer after electing the Medicare hospice benefit.

If the beneficiary transferred after electing the Medicare hospice benefit, enter the Start Date 2 of the benefit period in which the patient transferred. This date should match the “FROM” date submitted on the Notice of Change, TOB 8XC. If there was a Notice of Change of Ownership, TOB 8XE billed, then the “FROM” date would need to match the date on the 8XE.

COND CODES
Required

Effective for NOTRs with the "From" date on or after January 1, 2018.

Enter D0 (zero) to correct the discharge/revocation date previously submitted

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

OCC CDS/Date
Required

Effective for NOTRs with the "From" date on or after January 1, 2018.

Occurrence code 56 – Enter the incorrect discharge/revocation date reported on the original NOTR.

FAC.ZIP
Required

Enter the hospice's ZIP code (9-digit). The ZIP code entered must match the ZIP code in the Master Address field of the provider's address file at CGS.

Refer to the Claim Page 03 – Entering a Notice of Termination/Revocation – NOTR (8XB) for the remaining data elements that need to be submitted when correcting an NOE.

Additional FISS Claim Pages

Updated: 04.29.19

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