Claim Page 03 – Entering a Notice of Election (NOE) or Transfer NOE
Claim Page 03 (Map 1713) contains payer information, diagnosis code information, and physician information.
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 Name/Requirement | UB-04 Form Locator (FL) | Description | ||||
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CD |
N/A |
FISS defaults to a "Z". Do not change. NOEs should be submitted with Medicare as the primary payer. |
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PAYER |
FL 50 |
FISS will automatically plug "Medicare" into this field. |
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RI |
FL 52 |
Release of Information. Valid values are:
|
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MEDICAL RECORD NBR |
FL 3b |
Beneficiary's medical record number. |
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DIAG CODES |
FL67A-Q |
For claims with a "From" date prior to October 1, 2015, enter the ICD-9-CM diagnosis codes. For claims with a "From" date on or after October 1, 2015, enter the ICD-10-CM diagnosis code(s). (Maximum of 25 codes.) Note: Hospices may not report V-codes as the primary diagnosis on hospice claims. In addition, effective with dates of service on or after October 1, 2014, certain diagnosis codes as the principal diagnosis are prohibited, including debility, adult failure to thrive, as well as certain dementia codes. See Attachment A in Change Request 8877 for a list of all codes. |
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ATT PHYS NPI |
FL 76 |
Enter the National Provider Identifier (NPI) of the patient's attending physician. The attending physician is identified by the patient at the time they elect the hospice benefit. If the patient does not have an attending physician, enter the NPI of the certifying physician. |
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L |
FL 76 |
Enter the last name of the attending physician. If the patient does not have an attending physician, enter the last name of the certifying physician. |
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F |
FL 76 |
Enter the first name of the attending physician. If the patient does not have an attending physician, enter the first name of the certifying physician. |
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M |
N/A |
Enter the middle initial of the attending physician. |
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REF PHY NPI |
FL 78 and 79 |
Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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L |
FL 78 and 79 |
Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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F |
FL 78 and 79 |
Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
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M |
N/A |
Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician. |
Additional FISS Claim Pages
- Notice of Elections (NOEs)/Transfer NOE
- Hospice Claims
- Notice of Election Termination/Revocation (NOTR) – 8XB
Updated: 04.07.21