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

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

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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 MM8877 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 Guide 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 Menu 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

Notice of Elections (NOEs)/Transfer NOE
- Claim Page 01
- Claim Page 03
Hospice Claims
Notice of Election Termination/Revocation (NOTR) – 8XB
- Claim Page 03

Updated: 04.19.21