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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
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  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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

A Notice of Termination/Revocation (NOTR), also known by its type of bill - 8XB must be submitted to, and accepted by, CGS within 5 calendar days after the hospice discharge or revocation, unless a final hospice claim has already been submitted. To be accepted by CGS, the NOTR must be free of billing or keying errors that would cause the NOTR to be returned or rejected. Refer to MM8877External PDF for additional information.

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). Refer to CMS 837I NOE Companion GuideExternal PDF for the required elements.

The screenprints and tables below indicate what fields are required, and what data is required in each field. If information is not entered correctly, your NOTR will be returned to you for correction (RTP).

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 NOTR Page 01 – MAP 1711

Field Name/Requirement

UB-04 Form Locator (FL)

Description

MID
Required

FL 60

Enter the beneficiary's Medicare ID number

TOB
Required

FL 4

81B (nonhospital based)

82B (Hospital-based)

NPI
Required

FL 56

Enter your National Provider Identifier (NPI)

PAT. CNTL#
Optional

FL 3a

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

STMT DATES FROM/TO
Required

FL 6

Enter the start date of the hospice election period as the “FROM” date.

Example: The election period in which the discharge/revocation occurred is 04/16/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 must match the START DATE 2 on the benefit period that initiated the transfer. The START DATE 2 field is available on the FISS DDE MAP175I (Inquiry Option 10, Beneficiary/CWF). Refer to the FISS DDE Guide, Chapter Three: Inquiry MenuPDF for additional information.

If the revocation follows a change of ownership, the FROM date must match the OWNER CHANGE start date on the benefit period.

Enter the date the termination/revocation is effective in the "TO" field.

LAST
Required

FL 8

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

FIRST
Required

FL 8

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

DOB
Required

FL 8

Enter the beneficiary's date of birth.

ADDR
Required

FL 9

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

ZIP
Required

FL 9

Enter the beneficiary's zip code.

SEX
Required

FL 11

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

M= Male F=Female

ADMIT DATE
Required

FL 12

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.

FAC.ZIP
Required

FL 1

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.

Additional FISS Claim Pages

Updated: 04.19.21

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