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Claim Page 03 – Entering a Notice of Termination/Revocation - NOTR (8XB)

Claim Page 03 (MAP 1713) contains payer information, diagnosis code information, and physician information.

example

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 03 – MAP 1713

Field Name/Requirement

Description

CD
Required

Enter "Z" on line A.

PAYER
Required

FISS Will automatically plug "Medicare" into this field.

RI
Required

Release of information.

Valid values are:
I     Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes
 Yes, provider has a signed statement permitting release of information

MEDICAL RECORD NBR
Optional

Beneficiary’s medical record number.

ATT PHYS NPI
Required

Enter the NPI of the patient’s attending physician. If the patient does not have an attending physician, enter the NPI of the certifying physician.

L
Required

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.

F
Required

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.

M
Optional

Enter the middle initial of the attending physician.

REF PHYS NPI
Conditionally Required

Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician.

L
Conditionally Required

Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

F
Conditionally Required

Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

M
Optional

Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

Additional FISS Claim Pages

 

Updated:  10.05.18

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