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Claim Page 03 – Entering a RAP or Claim

Claim Page 03 (Map 1713) contains payer information, diagnosis/procedure code information, and physician information.

Claim Page 03 (Map 1713)

Key:

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

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Field Descriptions for Claim Page 03 – Map 1713

The MID, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Descriptions for Claim Page 03 – Map 1713
Field Description
CD
Required
Primary payer code.

Valid values are:
Z – Medicare
C – Conditional Medicare Secondary Payer (MSP) Payment

See the Medicare Secondary Payer (MSP) Web page for detailed MSP information.

Note: Providers should submit RAPs showing Medicare as primary payer, regardless of any MSP involvement.

The following payer codes are only used on lines B (secondary payer) and C (tertiary payer) to identify supplemental insurance payers.

1 – Medicaid
2 – Blue Cross
3 – Other
PAYER
Conditionally Required
Payer name.

FISS will automatically insert the payer name "Medicare" in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, you must enter the name of the other insurer on the corresponding A, B or C line.
OSCAR
Conditionally Required
Medicare provider number.

FISS will automatically insert your OSCAR number, also known as your Provider Transaction Access Number (PTAN), in this field when the payer code (CD field) for this line is a "Z". If a supplemental insurer is listed, or when billing Medicare conditionally, enter your provider number for the other insurer on the corresponding A, B or C line.
RI
Required
Release of Information.

Valid values are:

I Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes,
Y Yes, provider has a signed statement permitting release of information.
MEDICAL RECORD NBR
Optional
Beneficiary's medical record number.
DIAG CODES
Required
Key the ICD-9-CM/ICD-10-CM diagnosis codes (25 codes maximum).
RAPs with a "From" and "To" (or through) date prior to October 1, 2015, must include ICD-9 codes. RAPs with a "From" and "To" (or through) date on or after October 1, 2015, must include ICD-10 codes.

Final claimswith a "To" (or through) date prior to October 1, 2015, must include ICD-9 codes. If the "To" date is on or after October 1, 2015, ICD-10 codes must be reported.

Final claims with services spanning the ICD-10 implementation date, October 1, 2015, must include ICD-10 codes. Refer to the SE1410 article, "Special Instructions for the International Classification of Diseases, Clinical Modification 10th Edition (ICD-10-CM) Coding on Home Health Episodes that Span October 1, 2015External Website" for additional information.
ATT PHYS
NPI
Required
Key the national provider identifier of the attending physician who signs the patient's plan of care.

FISS edits HH PPS billing transactions to ensure attending physician's NPI is valid and that the attending physician is enrolled in Medicare, and is in Medicare's Provider Enrollment, Change and Ownership System (PECOS). As a resource, the PECOS Monthly Ordering and ReferringExternal Websitereport is available on the CMS website and contains the NPI for all physicians who are of a type/specialty that are eligible to order and refer beneficiaries for home health services. See Medicare Learning Network (MLN) Matters articles, MM6856External PDFand SE1305External PDFfor more information on this topic. For a list of physician specialties and codes, refer to the Medicare Claims Processing Manual, Pub. 100-04, Ch. 26, §10.8.2External PDF.

Note: When submitting services for the influenza or pneumococcal pneumonia vaccine and the administration via the 'Home Health' Claims Entry Option 26, enter the agency's NPI.
L
Required
Key the last name of the attending physician who signs the patient's plan of care. FISS edits the attending physician's last name on HH PPS billing transactions to ensure that the attending physician is enrolled in Medicare, and is in Medicare's Provider Enrollment, Change and Ownership System (PECOS). As a resource, the PECOS Monthly Ordering and ReferringExternal Websitereport is available on the CMS website and contains the NPI for all physicians who are of a type/specialty that are eligible to order and refer beneficiaries for home health services. See Medicare Learning Network (MLN) Matters articles, MM6856External PDFand SE1305External PDFfor more information on this topic. For a list of physician specialties and codes, refer to the Medicare Claims Processing Manual, Pub. 100-04, Ch. 26, §10.8.2External PDF.

Note: When submitting services for the influenza or pneumococcal pneumonia vaccine and the administration via the 'Home Health' Claims Entry Option 26, enter "Roster".
F
Required
Key the first name of the attending physician who signs the patient's plan of care. FISS edits the attending physician's first name on HH PPS billing transactions to ensure that the attending physician is enrolled in Medicare, and is in Medicare's Provider Enrollment, Change and Ownership System (PECOS). As a resource, the PECOS Monthly Ordering and ReferringExternal Websitereport is available on the CMS website and contains the NPI for all physicians who are of a type/specialty that are eligible to order and refer beneficiaries for home health services. See Medicare Learning Network (MLN) Matters articles, MM6856External PDFand SE1305External PDFfor more information on this topic. For a list of physician specialties and codes, refer to the Medicare Claims Processing Manual, Pub. 100-04, Ch. 26, §10.8.2External PDF.

Note: When submitting services for the influenza or pneumococcal pneumonia vaccine and the administration via the 'Home Health' Claims Entry Option 26, enter "Bill".
M
Optional
Key the middle initial of the attending physician who signs the patient's plan of care (not required).
REF PHYS NPI
Conditional
For HH PPS claims (type of bill 32X) report the national provider identifier of the physician who certifies / recertifies the patient's eligibility for home health services, if different than the attending physician. Applicable only for home health claims with episodes that begin on or after July 1, 2014. Refer to the Medicare Learning Network (MLN) Matters article, MM8441External PDFfor additional information.

For home health outpatient claims (type of bill 34X), report the referring physician's national provider identifier. Refer to the Medicare Learning Network (MLN) Matters article, MM7785External PDF for additional information.
L
Conditional
Key the last name of the physician who certifies / recertifies the patient's eligibility for home health services, if different than the attending physician (type of bill 32X).

Referring physician's last name (type of bill 34X).
F
Conditional
Key the first name of the physician who certifies / recertifies the patient's eligibility for home health services, if different than the attending physician (type of bill 32X).

Referring physician's first name (type of bill 34X).
M
Optional
Key the middle initial of the physician who certifies / recertifies the patient's eligibility for home health services, if different than the attending physician (type of bill 32X).

Referring physician's middle initial (not required) (type of bill 34X).

Additional FISS Claim Pages

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Updated: 10.02.18

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