Inclusion and Exclusion of Specified Categories of Adjustment

80.8 - Inclusion and Exclusion of Specified Categories of Adjustment Claims for Coordination of Benefits Agreement (COBA) Crossover Purposes (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) 1. CWF Inclusion of Adjustment Claims Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion of adjustment claims option, along with 1-byte file displacement, within its version of the COIF; and 2) accept and process this new field when the BCRC transmits it as part of its regular COIF updates. Upon receipt of a COIF that features a COBA identification number (ID) with specifications to include adjustment claims only, the CWF shall select only those claims for COBA crossover that meet the following specifications: 1) The claim’s action code=3, entry code=5, or claim adjustment indicator=“A”— all of which designate an “adjustment” claim; and 2) The claim meets no other exclusion criteria, as specified on the COIF, or does not meet the NPI placeholder value by-pass exclusion logic. With the implementation of this change, the CWF shall continue to select adjustment claims only if it previously selected the “original” claim for crossover (logic for adjustment indicator “R”; see §80.4 of this chapter for additional details regarding this logic). If the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the new designated RAC adjustment indicator field, CWF shall select the claim in accordance with the COBA trading partner’s claims selection criteria specified on the COIF. 2. CWF Inclusion of Two Categories of Mass Adjustment Claims for Crossover Purposes Effective January 5, 2009, the CWF system shall 1) create the newly defined inclusion of mass adjustment claims—MPFS updates and mass adjustment claims—other options, along with accompanying 1-byte file displacement indicators, within its version of the COIF; and 2) accept and process these new fields when the BCRC transmits them as part of its regular COIF updates. Upon receipt of a HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim transaction, CWF shall take the following actions: 1) Verify that the claim transaction contains an “M” or “O” mass adjustment claim header indicator; 2) verify that the claim’s action code=3, or entry code=5, or adjustment header indicator=A; 3) check the COIF to determine if the COBA trading partner wishes to include mass adjustment claims—MPFS or mass adjustment claims--other; 4) include the claim for crossover, unless the “original” claim was not crossed over (logic for crossover disposition indicator “R”) or the claim meets any claims exclusion criteria as specified on the COIF. If the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the mass adjustment indicator field, CWF shall select the claim per the COBA trading partner’s claims selection criteria, as specified on the COIF. 3. CWF Inclusion and Exclusion of Recovery Audit A/B MAC or DME MAC (RAC)- Initiated Adjustment Claims At CMS’s direction, the BCRC has modified the COIF to allow for the unique inclusion and exclusion of RAC-initiated adjustment claims. The CWF system shall 1) create the newly defined inclusion and exclusion of RAC-initiated adjustment options, along with accompanying 1-byte file displacement, on its version of the COIF; and 2) accept and process these new fields when the BCRC transmits them as part of its regular COIF updates. Effective January 5, 2009, the CWF maintainer created a 1-byte RAC adjustment value in the header of its HUIP, HUOP, HUHH, HUHC, HUBC, and HUDC claims transactions (valid values= “R” or spaces.) The CWF maintainer shall, in addition, include the 1-byte RAC adjustment indicator in the header of the claim that is posted to history on HIMR, thereby ensuring that CWF displays the indicator when a user accesses the INPH, OUTH, PTBH, DMEH, and related HIMR screens. Shared System Actions All shared systems shall develop a method for uniquely identifying all varieties of RAC- requested adjustments, which occur as the result of post-payment review activities. Prior to sending its processed 11X and 12X type of bill RAC adjustment transactions to CWF for normal verification and validation, the Part A shared system shall input an “R” indicator in the newly defined header field of its HUIP claims transactions if the RAC- initiated adjustment claim meets either of the following conditions: 1) The claim recovery action resulted in Medicare changing its payment decision from paid to denied (i.e., Medicare paid $0.00 as the result of the adjustment performed); or 2) The claim recovery action resulted in a Medicare adjusted payment amount that is equal to or greater than the amount of the inpatient hospital deductible. Prior to sending RAC-initiated adjustment claims with all other type of bill designations (bill types other than 11X and 12X) to CWF for normal processing, the Part A shared system shall input an “R” indicator in the newly defined header field of the HUOP, HUHH, and HUHC claim transaction. Prior to sending their processed RAC adjustment transactions to CWF for normal verification and validation, the Part B and DME MAC shared systems shall input an “R” indicator in the newly defined header field of their HUBC and HUDC claim transactions. (See chapter 28, §70.6 for more details.) CWF Actions Upon receipt of a claim that contains an “R” in its header in the newly defined field, CWF shall take the additional following actions: 1) Verify that the claim’s action code=3, entry code=5, or header claim adjustment indicator=A; 2) Check the COIF to determine if the COBA trading partner wishes to include RAC- initiated claims; 3) Include the claim for crossover, unless the “original” claim was not crossed over (logic for crossover disposition indicator “R”) or the claim meets any other claims exclusions specified on the COIF; or 4) Exclude the claim if the COIF specifies exclusion of RAC-initiated adjustment claims. In addition, if the incoming HUIP, HUOP, HUHH, HUHC, HUBC, or HUDC claim contains spaces in the new designated RAC adjustment indicator field, CWF shall select the claim in accordance with the COBA trading partner’s claims selection criteria, as specified on the COIF.