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Claim Page 01 – Entering a Notice of Election (NOE)/Transfer NOE

The following information provides guidance on how to enter these billing transactions in the Fiscal Intermediary Standard System (FISS) Claims/Attachments option (FISS Main Menu option 02) via Direct Data Entry (DDE).  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. 

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.

screenshot

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.

1st Digit
8 – Hospice

2nd Digit
1 – Hospice (nonhospital based)
2 – Hospice (hospital based)

3rd Digit
A – Admission/Election Notice
C – Change of Hospice Provider (i.e. hospice transfer)

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 FROM date of this hospice election or the date of hospice transfer in MMDDYY format. A TO date is not required on NOEs.

LAST
Required

Enter the beneficiary's last name exactly as it appears on the Medicare card or 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 Medicare card or 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 effective date of the hospice election or date of hospice transfer.

OCC CDS/DATE
Required

Occurrence code 27 and the date of certification. This date must match the FROM date and ADMIT DATE, except for transfer NOEs. An occurrence code 27 is not required on a transfer NOE, unless the date of transfer is also the first day of the next benefit period.

FAC.ZIP
Required

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

Additional FISS Claim Pages

Updated: 10.02.18

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