1
CMS RIF REPORT
AS OF: 10/03/2008
NAME LENGTH BEG END CONTENTS
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*** Carrier Claim Record (NCH)
VAR 1 4863 REC
Carrier claim record (other than DMERC) for version I
of the NCH.
STANDARD ALIAS : CARR_CLM_REC
SYSTEM ALIAS : UTLCARRI
LIMITATIONS :
REFER TO :
CARR_LINE_RX_NUM_LIM
1. Carrier Claim Fixed Group
375 1 375 GRP
Fixed portion of the carrier claim record for
version I of the NCH.
STANDARD ALIAS : CARR_CLM_FIX_GRP
2. Claim Record Identification Group
8 1 8 GRP
Effective with Version 'I' the record
length, version code, record identification,
code and NCH derived claim type code were moved
to this group for internal NCH processing.
STANDARD ALIAS : CLM_REC_IDENT_GRP
3. Record Length Count
3 1 3 PACK
Effective with Version H, the count (in bytes)
of the length of the claim record.
NOTE: During the Version H conversion this field
was populated with data throughout history
(back to service year 1991).
DB2 ALIAS : REC_LNGTH_CNT
SAS ALIAS : REC_LEN
STANDARD ALIAS : REC_LNGTH_CNT
LENGTH : 5 SIGNED : Y
SOURCE : NCH
4. NCH Near-Line Record Version Code
1 4 4 CHAR
The code indicating the record version of the Nearline file
where the institutional, carrier or DMERC claims data are
stored.
DB2 ALIAS : NCH_REC_VRSN_CD
SAS ALIAS : REC_LVL
STANDARD ALIAS : NCH_NEAR_LINE_REC_VRSN_CD
TITLE ALIAS : NCH_VERSION
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CLM_NEAR_LINE_REC_VRSN_CD.
SOURCE : NCH
CODE TABLE : NCH_NEAR_LINE_REC_VRSN_TB
5. NCH Near Line Record Identification Code
1 5 5 CHAR
A code defining the type of claim record being processed.
COMMON ALIAS : RIC
DB2 ALIAS : NEAR_LINE_RIC_CD
SAS ALIAS : RIC_CD
STANDARD ALIAS : NCH_NEAR_LINE_RIC_CD
TITLE ALIAS : RIC
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
RIC_CD.
SOURCE : NCH
CODE TABLE : NCH_NEAR_LINE_RIC_TB
6. NCH MQA RIC Code
1 6 6 CHAR
Effective with Version H, the code used (for internal
editing purposes) to identify the record being processed
through CMS' CWFMQA system.
NOTE: Beginning with NCH weekly process date 10/3/97 this
field was populated with data. Claims processed prior
to 10/3/97 will contain spaces in this field.
DB2 ALIAS : NCH_MQA_RIC_CD
SAS ALIAS : MQA_RIC
STANDARD ALIAS : NCH_MQA_RIC_CD
TITLE ALIAS : MQA_RIC
LENGTH : 1
SOURCE : NCH QA PROCESS
CODE TABLE : NCH_MQA_RIC_TB
7. NCH Claim Type Code
2 7 8 CHAR
The code used to identify the type of claim record being
processed in NCH.
NOTE1: During the Version H conversion this field was
populated with data throughout history (back to
service year 1991).
NOTE2: During the Version I conversion this field was
expanded to include inpatient 'full' encounter
claims (for service dates after 6/30/97).
DB2 ALIAS : NCH_CLM_TYPE_CD
SAS ALIAS : CLM_TYPE
STANDARD ALIAS : NCH_CLM_TYPE_CD
TITLE ALIAS : CLAIM_TYPE
LENGTH : 2
DERIVATIONS :
FFS CLAIM TYPE CODES DERIVED FROM:
NCH CLM_NEAR_LINE_RIC_CD
NCH PMT_EDIT_RIC_CD
NCH CLM_TRANS_CD
NCH PRVDR_NUM
INPATIENT 'FULL' ENCOUNTER TYPE CODE DERIVED FROM:
(Pre-HDC processing -- AVAILABLE IN NCH)
CLM_MCO_PD_SW
CLM_RLT_COND_CD
MCO_CNTRCT_NUM
MCO_OPTN_CD
MCO_PRD_EFCTV_DT
MCO_PRD_TRMNTN_DT
DERIVATION RULES:
SET CLM_TYPE_CD TO 10 (HHA CLAIM) WHERE THE
FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U'
2. PMT_EDIT_RIC_CD EQUAL 'F'
3. CLM_TRANS_CD EQUAL '5'
SET CLM_TYPE_CD TO 20 (SNF NON-SWING BED CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V'
2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
3. CLM_TRANS_CD EQUAL '0' OR '4'
4. POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y'
OR 'Z'
SET CLM_TYPE_CD TO 30 (SNF SWING BED CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V'
2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
3. CLM_TRANS_CD EQUAL '0' OR '4'
4. POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y'
OR 'Z'
SET CLM_TYPE_CD TO 40 (OUTPATIENT CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'W'
2. PMT_EDIT_RIC_CD EQUAL 'D'
3. CLM_TRANS_CD EQUAL '6'
SET CLM_TYPE_CD TO 50 (HOSPICE CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V'
2. PMT_EDIT_RIC_CD EQUAL 'I'
3. CLM_TRANS_CD EQUAL 'H'
SET CLM_TYPE_CD TO 60 (INPATIENT CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V'
2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
3. CLM_TRANS_CD EQUAL '1' '2' OR '3'
SET CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER
CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 -
12/4/00) WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_MCO_PD_SW = '1'
2. CLM_RLT_COND_CD = '04'
3. MCO_CNTRCT_NUM
MCO_OPTN_CD = 'C'
CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE
MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT
ENROLLMENT PERIODS
SET_CLM_TYPE_CD TO 61 (INPATIENT 'FULL' ENCOUNTER
CLAIM -- EFFECTIVE WITH HDC PROCESSING) WHERE THE
FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'V'
2. PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
3. CLM_TRANS_CD EQUAL '1' '2' OR '3'
4. FI_NUM = 80881
SET CLM_TYPE_CD TO 71 (RIC O non-DMEPOS CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'O'
2. HCPCS_CD not on DMEPOS table
SET CLM_TYPE_CD TO 72 (RIC O DMEPOS CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'O'
2. HCPCS_CD on DMEPOS table (NOTE: if one or
more line item(s) match the HCPCS on the
DMEPOS table).
SET CLM_TYPE_CD TO 81 (RIC M non-DMEPOS DMERC
CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'M'
2. HCPCS_CD not on DMEPOS table
SET CLM_TYPE_CD TO 82 (RIC M DMEPOS DMERC CLAIM)
WHERE THE FOLLOWING CONDITIONS ARE MET:
1. CLM_NEAR_LINE_RIC_CD EQUAL 'M'
2. HCPCS_CD on DMEPOS table (NOTE: if one or
more line item(s) match the HCPCS on the
DMEPOS table).
SOURCE : NCH
CODE TABLE : NCH_CLM_TYPE_TB
8. Carrier/DMERC Claim Link Group
125 9 133 GRP
Effective with Version 'I', this group
was added to the carrier and DMERC records
to keep fields common across all record types
in the same position. Due to OP PPS, several
fields on the Institutional record had to be
moved to a link group so those same fields had
to be moved on the carrier records eventhough
OP PPS only affects institutional claims.
STANDARD ALIAS : CARR_DMERC_CLM_LINK_GRP
9. Claim Locator Number Group
11 9 19 GRP
This number uniquely identifies the beneficiary in
the NCH Nearline.
COMMON ALIAS : HIC
STANDARD ALIAS : CLM_LCTR_NUM_GRP
TITLE ALIAS : HICAN
10. Beneficiary Claim Account Number
9 9 17 CHAR
The number identifying the primary beneficiary
under the SSA or RRB programs submitted.
COMMON ALIAS : CAN
DB2 ALIAS : BENE_CLM_ACNT_NUM
SAS ALIAS : CAN
STANDARD ALIAS : BENE_CLM_ACNT_NUM
TITLE ALIAS : CAN
LENGTH : 9
SOURCE : SSA,RRB
LIMITATIONS :
RRB-issued numbers contain an overpunch in
the first position that may appear as a plus
zero or A-G. RRB-formatted numbers may
cause matching problems on non-IBM machines.
11. NCH Category Equatable Beneficiary Identification Code
2 18 19 CHAR
The code categorizing groups of BICs
representing similar relationships between
the beneficiary and the primary wage earner.
The equatable BIC module electronically matches
two records that contain different BICs where
it is apparent that both are records for the
same beneficiary. It validates the BIC and
returns a base BIC under which to house the
record in the National Claims History (NCH)
databases. (All records for a beneficiary
are stored under a single BIC.)
COMMON ALIAS : NCH_BASE_CATEGORY_BIC
DB2 ALIAS : CTGRY_EQTBL_BIC
SAS ALIAS : EQ_BIC
STANDARD ALIAS : NCH_CTGRY_EQTBL_BIC_CD
TITLE ALIAS : EQUATED_BIC
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CTGRY_EQTBL_BENE_IDENT_CD.
SOURCE : BIC EQUATE MODULE
CODE TABLE : CTGRY_EQTBL_BENE_IDENT_TB
12. Beneficiary Identification Code
2 20 21 CHAR
The code identifying the type of relationship between an
individual and a primary Social Security Administration
(SSA) beneficiary or a primary Railroad Board (RRB)
beneficiary.
COMMON ALIAS : BIC
DA3 ALIAS : BENE_IDENT_CODE
DB2 ALIAS : BENE_IDENT_CD
SAS ALIAS : BIC
STANDARD ALIAS : BENE_IDENT_CD
TITLE ALIAS : BIC
LENGTH : 2
SOURCE : SSA/RRB
EDIT RULES :
EDB REQUIRED FIELD
CODE TABLE : BENE_IDENT_TB
13. NCH State Segment Code
1 22 22 CHAR
The code identifying the segment of the NCH Nearline file
containing the beneficiary's record for a specific service
year. Effective 12/96, segmentation is by CLM_LCTR_NUM,
then final action sequence within residence state. (Prior
to 12/96, segmentation was by ranges of county codes within
the residence state.)
DB2 ALIAS : NCH_STATE_SGMT_CD
SAS ALIAS : ST_SGMT
STANDARD ALIAS : NCH_STATE_SGMT_CD
TITLE ALIAS : NEAR_LINE_SEGMENT
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
BENE_STATE_SGMT_NEAR_LINE_CD.
SOURCE : NCH
CODE TABLE : NCH_STATE_SGMT_TB
14. Beneficiary Residence SSA Standard State Code
2 23 24 CHAR
The SSA standard state code of a beneficiary's residence.
DA3 ALIAS : SSA_STANDARD_STATE_CODE
DB2 ALIAS : BENE_SSA_STATE_CD
SAS ALIAS : STATE_CD
STANDARD ALIAS : BENE_RSDNC_SSA_STD_STATE_CD
TITLE ALIAS : BENE_STATE_CD
LENGTH : 2
COMMENTS :
1. Used in conjunction with a county code, as
selection criteria for the determination of
payment rates for HMO reimbursement.
2. Concerning individuals directly billable for
Part B and/or Part A premiums, this element
is used to determine if the beneficiary
will receive a bill in English or Spanish.
3. Also used for special studies.
SOURCE : SSA/EDB
EDIT RULES :
OPTIONAL: MAY BE BLANK
CODE TABLE : GEO_SSA_STATE_TB
15. Claim From Date
8 25 32 NUM
The first day on the billing statement
covering services rendered to the bene-
ficiary (a.k.a. 'Statement Covers From Date').
NOTE: For Home Health PPS claims, the 'from'
date and the 'thru' date on the RAP (initial
claim) must always match.
DB2 ALIAS : CLM_FROM_DT
SAS ALIAS : FROM_DT
STANDARD ALIAS : CLM_FROM_DT
TITLE ALIAS : FROM_DATE
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
16. Claim Through Date
8 33 40 NUM
The last day on the billing statement covering
services rendered to the beneficiary (a.k.a
'Statement Covers Thru Date').
NOTE: For Home Health PPS claims, the 'from'
date and the 'thru' date on the RAP (initial
claim) must always match.
DB2 ALIAS : CLM_THRU_DT
SAS ALIAS : THRU_DT
STANDARD ALIAS : CLM_THRU_DT
TITLE ALIAS : THRU_DATE
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
17. NCH Weekly Claim Processing Date
8 41 48 NUM
The date the weekly NCH database load
process cycle begins, during which the claim
records are loaded into the Nearline file.
This date will always be a Friday, although
the claims will actually be appended to the
database subsequent to the date.
DB2 ALIAS : NCH_WKLY_PROC_DT
SAS ALIAS : WKLY_DT
STANDARD ALIAS : NCH_WKLY_PROC_DT
TITLE ALIAS : NCH_PROCESS_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
HCFA_CLM_PROC_DT.
SOURCE : NCH
EDIT RULES :
YYYYMMDD
18. CWF Claim Accretion Date
8 49 56 NUM
The date the claim record is accreted (posted/
processed) to the beneficiary master record
at the CWF host site and authorization for
payment is returned to the fiscal interme-
diary or carrier.
DB2 ALIAS : CWF_CLM_ACRTN_DT
SAS ALIAS : ACRTN_DT
STANDARD ALIAS : CWF_CLM_ACRTN_DT
TITLE ALIAS : ACCRETION_DT
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
19. CWF Claim Accretion Number
2 57 58 PACK
The sequence number assigned to the claim
record when accreted (posted/processed) to
the beneficiary master record at the CWF host
site on a given date. This element indicates
the position of the claim within that day's
processing at the CWF host. **(Exception: If
the claim record is missing the accretion date
CMS' CWFMQA system places a zero in the
accretion number.
DB2 ALIAS : CWF_CLM_ACRTN_NUM
SAS ALIAS : ACRTN_NM
STANDARD ALIAS : CWF_CLM_ACRTN_NUM
TITLE ALIAS : ACCRETION_NUMBER
LENGTH : 3 SIGNED : Y
SOURCE : CWF
20. Carrier Claim Control Number
15 59 73 CHAR
Unique control number assigned by a carrier
to a non-institutional claim.
COMMON ALIAS : CCN
DB2 ALIAS : CARR_CLM_CNTL_NUM
SAS ALIAS : CARRCNTL
STANDARD ALIAS : CARR_CLM_CNTL_NUM
TITLE ALIAS : CCN
LENGTH : 15
COMMENTS :
For the physician/supplier or DMERC claim, this
field allows CMS to associate each line item
with its respective claim.
SOURCE : CWF
EDIT RULES :
LEFT JUSTIFY
21. FILLER CHAR
38 74 111
DB2 ALIAS : FILLER
LENGTH : 38
22. NCH Daily Process Date
8 112 119 NUM
Effective with Version H, the date the claim record was
processed by CMS' CWFMQA system (used for internal editing
purposes).
Effective with Version I, this date is used in conjunction
with the NCH Segment Link Number to keep claims with
multiple records/ segments together.
NOTE1: With Version 'H' this field was populated with
data beginning with NCH weekly process date 10/3/97.
Under Version 'I' claims prior to 10/3/97, that were
blank under Version 'H', were populated with a date.
DB2 ALIAS : NCH_DAILY_PROC_DT
SAS ALIAS : DAILY_DT
STANDARD ALIAS : NCH_DAILY_PROC_DT
TITLE ALIAS : DAILY_PROCESS_DT
LENGTH : 8 SIGNED : N
SOURCE : NCH
EDIT RULES :
YYYYMMDD
23. NCH Segment Link Number
5 120 124 PACK
Effective with Version 'I', the system gen-
erated number used in conjunction with the
NCH daily process date to keep records/segments
belonging to a specific claim together.
This field was added to ensure that records/
segments that come in on the same batch with
the same identifying information in the link
group are not mixed with each other.
NOTE: During the Version I conversion this
field was populated with data throughout
history (back to service year 1991).
DB2 ALIAS : NCH_SGMT_LINK_NUM
SAS ALIAS : LINK_NUM
STANDARD ALIAS : NCH_SGMT_LINK_NUM
TITLE ALIAS : LINK_NUM
LENGTH : 9 SIGNED : Y
SOURCE : NCH
24. Claim Total Segment Count
2 125 126 NUM
Effective with Version I, the count used
to identify the total number of segments
associated with a given claim. Each claim
could have up to 10 segments.
NOTE: During the Version I conversion, this
field was populated with data throughout
history (back to service year 1991).
For institutional claims, the count
for claims prior to 7/00 will be 1 or 2
(1 if 45 or less revenue center lines on a
claim and 2 if more than 45 revenue center
lines on a claim). For noninstitutional
claims, the count will always be 1.
DB2 ALIAS : TOT_SGMT_CNT
SAS ALIAS : SGMT_CNT
STANDARD ALIAS : CLM_TOT_SGMT_CNT
TITLE ALIAS : SEGMENT_COUNT
LENGTH : 2 SIGNED : N
SOURCE : CWF
25. Claim Segment Number
2 127 128 NUM
Effective with Version I, the number used
to identify an actual record/segment (1 - 10)
associated with a given claim.
NOTE: During the Version I conversion this
field was populated with data throughout
history (back to service year 1991).
For institutional claims prior to 7/00,
this number will be either 1 or 2. For
noninstitutional claims, the number will
always be 1.
DB2 ALIAS : CLM_SGMT_NUM
SAS ALIAS : SGMT_NUM
STANDARD ALIAS : CLM_SGMT_NUM
TITLE ALIAS : SEGMENT_NUMBER
LENGTH : 2 SIGNED : N
SOURCE : CWF
26. Claim Total Line Count
3 129 131 NUM
Effective with Version I, the count used to
identify the total number of revenue center
lines associated with the claim.
NOTE: During the Version I conversion this
field was populated with data throughout
history (back to service year 1991).
Prior to Version 'I', the maximum line count
will be no more than 58. Effective with Version
'I', the maximum line count could be 450.
DB2 ALIAS : TOT_LINE_CNT
SAS ALIAS : LINECNT
STANDARD ALIAS : CLM_TOT_LINE_CNT
TITLE ALIAS : TOTAL_LINE_COUNT
LENGTH : 3 SIGNED : N
SOURCE : CWF
27. Claim Segment Line Count
2 132 133 NUM
Effective with Version I, the count used
to identify the number of lines on a record/
segment.
NOTE: During the Version I conversion this
field was populated with data throughout
history (back to service year 1991).
The maximum line count per record/segment
on the revenue center trailer is 45. The
maximum number of lines on carrier and DMERC
claims are 13.
DB2 ALIAS : SGMT_LINE_CNT
SAS ALIAS : SGMTLINE
STANDARD ALIAS : CLM_SGMT_LINE_CNT
TITLE ALIAS : SEGMENT_LINE_COUNT
LENGTH : 2 SIGNED : N
SOURCE : CWF
28. Carrier/DMERC Claim Common 1 Group
194 134 327 GRP
Information common to both carrier and
DMERC claims for version I of NCH.
29. FILLER CHAR
5 134 138
DB2 ALIAS : FILLER
LENGTH : 5
30. Carrier Claim Entry Code
1 139 139 CHAR
Carrier-generated code describing whether the
Part B claim is an original debit, full credit,
or replacement debit.
DB2 ALIAS : CARR_CLM_ENTRY_CD
SAS ALIAS : ENTRY_CD
STANDARD ALIAS : CARR_CLM_ENTRY_CD
TITLE ALIAS : ENTRY_CD
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_ENTRY_CD.
SOURCE : CWF
31. FILLER CHAR
1 140 140
DB2 ALIAS : FILLER
LENGTH : 1
32. Claim Disposition Code
2 141 142 CHAR
Code indicating the disposition or outcome of the processing
of the claim record.
DB2 ALIAS : CLM_DISP_CD
SAS ALIAS : DISP_CD
STANDARD ALIAS : CLM_DISP_CD
TITLE ALIAS : DISPOSITION_CD
LENGTH : 2
SOURCE : CWF
CODE TABLE : CLM_DISP_TB
33. NCH Edit Disposition Code
2 143 144 CHAR
Effective with Version H, a code used (for internal editing
purposes) to indicate the disposition of the claim after
editing in the CWFMQA process.
NOTE: Beginning with NCH weekly process date 10/3/97 this
field was populated with data. Claims processed prior
to 10/3/97 will contain spaces in this field.
DB2 ALIAS : NCH_EDIT_DISP_CD
SAS ALIAS : EDITDISP
STANDARD ALIAS : NCH_EDIT_DISP_CD
TITLE ALIAS : NCH_EDIT_DISP
LENGTH : 2
SOURCE : NCH QA Process
CODE TABLE : NCH_EDIT_DISP_TB
34. NCH Claim BIC Modify H Code
1 145 145 CHAR
Effective with Version H, the code used (for internal
editing purposes) to identify a claim record that was
submitted with an incorrect HA, HB, or HC BIC.
NOTE: Beginning with NCH weekly process date 10/3/97 this
field was populated with data. Claims processed
prior to 10/3/97 will contain spaces in this field.
DB2 ALIAS : NCH_BIC_MDFY_CD
SAS ALIAS : BIC_MDFY
STANDARD ALIAS : NCH_CLM_BIC_MDFY_CD
TITLE ALIAS : BIC_MODIFY_CD
LENGTH : 1
SOURCE : NCH QA Process
CODE TABLE : NCH_CLM_BIC_MDFY_TB
35. Beneficiary Residence SSA Standard County Code
3 146 148 CHAR
The SSA standard county code of a beneficiary's residence.
DB2 ALIAS : BENE_SSA_CNTY_CD
SAS ALIAS : CNTY_CD
STANDARD ALIAS : BENE_RSDNC_SSA_STD_CNTY_CD
TITLE ALIAS : BENE_COUNTY_CD
LENGTH : 3
SOURCE : SSA/EDB
EDIT RULES :
OPTIONAL: MAY BE BLANK
36. Carrier Claim Receipt Date
8 149 156 NUM
The date the carrier receives the non-
institutional claim.
DB2 ALIAS : CLM_RCPT_DT
SAS ALIAS : RCPT_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version 'H' this field was named:
FICARR_CLM_RCPT_DT.
SOURCE : CWF
EDIT RULES :
YYYYMMDD
37. Carrier Claim Scheduled Payment Date
8 157 164 NUM
The scheduled date of payment to the physician
or supplier, as appearing on the original non-
institutional claim sent to the CWF host.
**Note: This date is considered to be the
date paid since no additional information as
to the actual payment date is available.
DB2 ALIAS : CARR_SCHLD_PMT_DT
SAS ALIAS : SCHLD_DT
STANDARD ALIAS : CARR_CLM_SCHLD_PMT_DT
TITLE ALIAS : SCHLD_PMT_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
FICARR_CLM_PMT_DT.
SOURCE : CWF
EDIT RULES :
YYYYMMDD
38. CWF Forwarded Date
8 165 172 NUM
Effective with Version H, the date CWF forwarded the claim
record to CMS (used for internal editing purposes).
NOTE: Beginning with NCH weekly process date 10/3/97 this
field was populated with data. Claims processed
prior to 10/3/97 will contain zeroes in this field.
DB2 ALIAS : CWF_FRWRD_DT
SAS ALIAS : FRWRD_DT
STANDARD ALIAS : CWF_FRWRD_DT
TITLE ALIAS : FORWARD_DT
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
39. Carrier Number
5 173 177 CHAR
The identification number assigned by CMS to a
carrier authorized to process claims from a
physician or supplier.
Effective July 2006, the Medicare Administrative
Contractors (MACs) began replacing the existing
carriers and started processing physician or
supplier claim records for states assigned
to its jurisdiction.
NOTE: The 5-position MAC number will be housed in
the existing CARR_NUM field. During the transi-
tion from a carrier to a MAC the CARR_NUM field
could contain either a Carrier number or a MAC
number. See the CARR_NUM table of codes to
identify the new MAC numbers and their effective
dates.
DB2 ALIAS : CARR_NUM
SAS ALIAS : CARR_NUM
STANDARD ALIAS : CARR_NUM
TITLE ALIAS : CARRIER
LENGTH : 5
COMMENTS :
Prior to Version H this field was named:
FICARR_IDENT_NUM.
SOURCE : CWF
CODE TABLE : CARR_NUM_TB
40. FILLER CHAR
8 178 185
DB2 ALIAS : FILLER
LENGTH : 8
41. CWF Transmission Batch Number
4 186 189 CHAR
Effective with Version H, the number assigned
to each batch of claims transactions sent from
CWF(used for internal editing purposes).
NOTE: Beginning 11/98, this field will be
populated with data. Claims processed
prior to 11/98 will contain spaces in
this field.
DB2 ALIAS : TRNSMSN_BATCH_NUM
SAS ALIAS : FIBATCH
STANDARD ALIAS : CWF_TRNSMSN_BATCH_NUM
TITLE ALIAS : BATCH_NUM
LENGTH : 4
SOURCE : CWF
42. Beneficiary Mailing Contact ZIP Code
9 190 198 CHAR
The ZIP code of the mailing address where the
beneficiary may be contacted.
DB2 ALIAS : BENE_MLG_ZIP_CD
SAS ALIAS : BENE_ZIP
STANDARD ALIAS : BENE_MLG_CNTCT_ZIP_CD
TITLE ALIAS : BENE_ZIP
LENGTH : 9
SOURCE : EDB
43. Beneficiary Sex Identification Code
1 199 199 CHAR
The sex of a beneficiary.
COMMON ALIAS : SEX_CD
DA3 ALIAS : SEX_CODE
DB2 ALIAS : BENE_SEX_IDENT_CD
SAS ALIAS : SEX
STANDARD ALIAS : BENE_SEX_IDENT_CD
TITLE ALIAS : SEX_CD
LENGTH : 1
SOURCE : SSA,RRB,EDB
EDIT RULES :
REQUIRED FIELD
CODE TABLE : BENE_SEX_IDENT_TB
44. Beneficiary Race Code
1 200 200 CHAR
The race of a beneficiary.
DA3 ALIAS : RACE_CODE
DB2 ALIAS : BENE_RACE_CD
SAS ALIAS : RACE
STANDARD ALIAS : BENE_RACE_CD
TITLE ALIAS : RACE_CD
LENGTH : 1
SOURCE : SSA
CODE TABLE : BENE_RACE_TB
45. Beneficiary Birth Date
8 201 208 NUM
The beneficiary's date of birth.
COMMON ALIAS : DOB
DA3 ALIAS : BIRTH_DATE
DB2 ALIAS : BENE_BIRTH_DT
SAS ALIAS : BENE_DOB
STANDARD ALIAS : BENE_BIRTH_DT
TITLE ALIAS : BENE_BIRTH_DATE
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
46. CWF Beneficiary Medicare Status Code
2 209 210 CHAR
The CWF-derived reason for a beneficiary's
entitlement to Medicare benefits, as of the
reference date (CLM_THRU_DT).
COBOL ALIAS : MSC
COMMON ALIAS : MSC
DB2 ALIAS : BENE_MDCR_STUS_CD
SAS ALIAS : MS_CD
STANDARD ALIAS : CWF_BENE_MDCR_STUS_CD
TITLE ALIAS : MSC
LENGTH : 2
DERIVATIONS :
CWF derives MSC from the following:
1. Date of Birth
2. Claim Through Date
3. Original/Current Reasons for entitlement
4. ESRD Indicator
5. Beneficiary Claim Number
Items 1,3,4,5 come from the CWF Beneficiary
Master Record; item 2 comes from the FI/Carrier
claim record. MSC is assigned as follows:
MSC OASI DIB ESRD AGE BIC
______ _____ _____ _____ _____ ______
10 YES N/A NO 65 and over N/A
11 YES N/A YES 65 and over N/A
20 NO YES NO under 65 N/A
21 NO YES YES under 65 N/A
31 NO NO YES any age T.
COMMENTS :
Prior to Version H this field was named:
BENE_MDCR_STUS_CD. The name has been changed
to distinguish this CWF-derived field from the
EDB-derived MSC (BENE_MDCR_STUS_CD).
SOURCE : CWF
CODE TABLE : BENE_MDCR_STUS_TB
47. Claim Patient 6 Position Surname
6 211 216 CHAR
The first 6 positions of the Medicare patient's
surname (last name) as reported by the provider
on the claim.
NOTE1: Prior to Version H, this field was only
present on the IP/SNF claim record.
Effective with Version H, this field is
present on all claim types.
NOTE2: For OP, HHA, Hospice and all Carrier
claims, data was populated beginning
with NCH weekly process 10/3/97. Claims
processed prior to 10/3/97 will contain
spaces in this field.
COMMON ALIAS : PATIENT_SURNAME
DB2 ALIAS : PTNT_6_PSTN_SRNM
SAS ALIAS : SURNAME
STANDARD ALIAS : CLM_PTNT_6_PSTN_SRNM_NAME
TITLE ALIAS : PATIENT_SURNAME
LENGTH : 6
SOURCE : CWF
48. Claim Patient 1st Initial Given Name
1 217 217 CHAR
The first initial of the Medicare patient's
given name (first name) as reported by the
provider on the claim.
NOTE1: Prior to Version H, this field was only
present on the IP/SNF claim record.
Effective with Version H, this field
is present on all claim types.
NOTE2: For OP, HHA, Hospice and all Carrier claims,
data was populated beginning with NCH
weekly process date 10/3/97. Claims
processed prior to 10/3/97 will contain
spaces in this field.
COMMON ALIAS : PATIENT_GIVEN_NAME
DB2 ALIAS : 1ST_INITL_GVN_NAME
SAS ALIAS : FRSTINIT
STANDARD ALIAS : CLM_PTNT_1ST_INITL_GVN_NAME
TITLE ALIAS : PATIENT_FIRST_INITIAL
LENGTH : 1
SOURCE : CWF
49. Claim Patient First Initial Middle Name
1 218 218 CHAR
The first initial of the Medicare patient's
middle name as reported by the provider on
the claim.
NOTE1: Prior to Version H, this field was only
present on the IP/SNF claim record.
Effective with Version H, this field is
present on all claim types.
NOTE2: For OP, HHA, Hospice and all Carrier claims,
data was populated beginning with NCH
weekly process date 10/3/97. Claims pro-
cessed prior to 10/3/97 will contain
spaces in this field.
COMMON ALIAS : PATIENT_MIDDLE_NAME
DB2 ALIAS : 1ST_INITL_MDL_NAME
SAS ALIAS : MDL_INIT
STANDARD ALIAS : CLM_PTNT_1ST_INITL_MDL_NAME
TITLE ALIAS : PATIENT_MIDDLE_INITIAL
LENGTH : 1
SOURCE : CWF
50. Beneficiary CWF Location Code
1 219 219 CHAR
The code that identifies the Common Working File
(CWF) location (the host site) where a beneficiary's
Medicare utilization records are maintained.
COMMON ALIAS : CWF_HOST
DB2 ALIAS : BENE_CWF_LOC_CD
SAS ALIAS : CWFLOCCD
STANDARD ALIAS : BENE_CWF_LOC_CD
TITLE ALIAS : CWF_HOST
LENGTH : 1
SOURCE : CWF
CODE TABLE : BENE_CWF_LOC_TB
51. Claim Principal Diagnosis Code
5 220 224 CHAR
The ICD-9-CM diagnosis code identifying the diagnosis,
condition, problem or other reason for the
admission/encounter/visit shown in the medical record to be
chiefly responsible for the services provided.
NOTE: Effective with Version H, this data is also
redundantly stored as the first occurrence of the diagnosis
trailer.
DB2 ALIAS : PRNCPAL_DGNS_CD
SAS ALIAS : PDGNS_CD
STANDARD ALIAS : CLM_PRNCPAL_DGNS_CD
TITLE ALIAS : PRINCIPAL_DIAGNOSIS
LENGTH : 5
SOURCE : CWF
EDIT RULES :
ICD-9-CM
52. FILLER CHAR
1 225 225
DB2 ALIAS : FILLER
LENGTH : 1
53. Carrier Claim Payment Denial Code
1 226 226 CHAR
The code on a noninstitutional claim indicating to
whom payment was made or if the claim was denied.
NOTE: Effective 4/1/02, this field was expanded
to two bytes to accommodate new values. The
NCH Nearline file did not expand the current
1-byte field but instituted a crosswalk of the
2-byte field to the 1-byte character value.
See table of code for the crosswalk.
DB2 ALIAS : CARR_PMT_DNL_CD
SAS ALIAS : PMTDNLCD
STANDARD ALIAS : CARR_CLM_PMT_DNL_CD
TITLE ALIAS : PMT_DENIAL_CD
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_PMT_DNL_CD.
SOURCE : CWF
CODE TABLE : CARR_CLM_PMT_DNL_TB
54. Claim Excepted/Nonexcepted Medical Treatment Code
1 227 227 CHAR
Effective with Version I, the code used to identify
whether or not the medical care or treatment received
by a beneficiary, who has elected care from a
Religious Nonmedical Health Care Institution (RNHCI),
is excepted or nonexcepted. Excepted is medical care
or treatment that is received involuntarily or is re-
quired under Federal, State or local law. Nonexcepted is
defined as medical care or treatment other than excepted.
DB2 ALIAS : EXCPTD_NEXCPTD_CD
SAS ALIAS : TRTMT_CD
STANDARD ALIAS : CLM_EXCPTD_NEXCPTD_TRTMT_CD
TITLE ALIAS : EXCPTD_NEXCPTD_CD
LENGTH : 1
SOURCE : CWF
CODE TABLE : CLM_EXCPTD_NEXCPTD_TRTMT_TB
55. Claim Payment Amount
6 228 233 PACK
Amount of payment made from the Medicare trust fund for the
services covered by the claim record. Generally, the amount
is calculated by the FI or carrier; and represents what was
paid to the institutional provider, physician, or supplier,
with the exceptions noted below. **NOTE: In some
situations, a negative claim payment amount may be pre-
sent; e.g., (1) when a beneficiary is charged the full
deductible during a short stay and the deductible exceeded
the amount Medicare pays; or (2) when a beneficiary is
charged a coinsurance amount during a long stay and the
coinsurance amount exceeds the amount Medicare pays (most
prevalent situation involves psych hospitals who are paid a
daily per diem rate no matter what the charges are.)
Under IP PPS, inpatient hospital services are paid based on
a predetermined rate per discharge, using the DRG patient
classification system and the PRICER program. On the IP
PPS claim, the payment amount includes the DRG outlier
approved payment amount, disproportionate share (since
5/1/86), indirect medical education (since 10/1/88), total
PPS capital (since 10/1/91). After 4/1/03, the payment
amount could also include a "new technology" add-on amount.
It does NOT include the pass-thru amounts (i.e., capital-
related costs, direct medical education costs, kidney
acquisition costs, bad debts); or any beneficiary-paid
amounts (i.e., deductibles and coinsurance); or any
any other payer reimbursement.
Under IRFPPS, inpatient rehabilitation services are paid
based on a predetermined rate per discharge, using the
Case Mix Group (CMG) classification system and the PRICER
program. From the CMG on the IRF PPS claim, payment is
based on a standard payment amount for operating and
capital cost for that facility (including routine and
ancillary services). The payment is adjusted for wage,
the % of low-income patients (LIP), locality, transfers,
interrupted stays, short stay cases, deaths, and high
cost outliers. Some or all of these adjustments could
apply. The CMG payment does NOT include certain pass-
through costs (i.e. bad debts, approved education
activities); beneficiary-paid amounts, other payer reim-
bursement,and other services outside of the scope of PPS.
Under LTCH PPS, long term care hospital services are paid
based on a predetermined rate per discharge based on the
DRG and the PRICER program. Payments are based on a
single standard Federal rate for both inpatient operating
and capital-related costs (including routine and ancillary
services), but do NOT include certain pass-through costs
(i.e. bad debts, direct medical education, new technologies
and blood clotting factors). Adjustments to the payment
may occur due to short-stay outliers, interrupted stays,
high cost outliers, wage index, and cost of living adjust-
ments.
Under SNF PPS, SNFs will classify beneficiaries using the
patient classification system known as RUGS III. For the
SNF PPS claim, the SNF PRICER will calculate/return the rate
for each revenue center line item with revenue center code =
'0022'; multiply the rate times the units count; and then
sum the amount payable for all lines with revenue center
code '0022' to determine the total claim payment amount.
Under Outpatient PPS, the national ambulatory payment
classification (APC) rate that is calculated for each APC
group is the basis for determining the total claim payment.
The payment amount also includes the outlier payment and
interest.
Under Home Health PPS, beneficiaries will be classified into
an appropriate case mix category known as the Home Health
Resource Group. A HIPPS code is then generated
corresponding to the case mix category (HHRG).
For the RAP, the PRICER will determine the payment amount
appropriate to the HIPPS code by computing 60% (for first
episode) or 50% (for subsequent episodes) of the case mix
episode payment. The payment is then wage index adjusted.
For the final claim, PRICER calculates 100% of the amount
due, because the final claim is processed as an adjustment
to the RAP, reversing the RAP payment in full. Although
final claim will show 100% payment amount, the provider will
actually receive the 40% or 50% payment. The payment may
also include outlier payments.
Exceptions: For claims involving demos and BBA encounter
data, the amount reported in this field may not just
represent the actual provider payment.
For demo Ids '01','02','03','04' -- claims contain
amount paid to the provider, except that special
'differentials' paid outside the normal payment system
are not included.
For demo Ids '05','15' -- encounter data 'claims'
contain amount Medicare would have paid under FFS,
instead of the actual payment to the MCO.
For demo Ids '06','07','08' -- claims contain actual
provider payment but represent a special negotiated
bundled payment for both Part A and Part B services.
To identify what the conventional provider Part A
payment would have been, check value code = 'Y4'. The
related noninstitutional (physician/supplier) claims
contain what would have been paid had there been no
demo.
For BBA encounter data (non-demo) -- 'claims' contain
amount Medicare would have paid under FFS, instead of
the actual payment to the BBA plan.
COMMON ALIAS : REIMBURSEMENT
DB2 ALIAS : CLM_PMT_AMT
SAS ALIAS : PMT_AMT
STANDARD ALIAS : CLM_PMT_AMT
TITLE ALIAS : REIMBURSEMENT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H the size of this field was S9(7)V99. Also,
the noninstitutional claim records carried this field as a line
item. Effective with Version H, this element is a claim level
field across all claim types (and the line item field has been
renamed.)
SOURCE : CWF
LIMITATIONS :
Prior to 4/6/93, on inpatient, outpatient, and
physician/supplier claims containing a
CLM_DISP_CD of '02', the amount shown as the Medicare
reimbursement does not take into consideration
any CWF automatic adjustments (involving erroneous
deductibles in most cases). In as many as 30% of
the claims (30% IP, 15% OP, 5% PART B), the
reimbursement reported on the claims may be over
or under the actual Medicare payment amount.
REFER TO :
PMT_AMT_EXCEDG_CHRG_AMT_LIM
EDIT RULES :
$$$$$$$$$CC
56. Carrier Claim Primary Payer Paid Amount
6 234 239 PACK
Effective with Version H, the amount of a
payment made on behalf of a Medicare bene-
ficiary by a primary payer other than Medicare,
that the provider is applying to covered
Medicare charges on a non-institutional claim.
NOTE: During the Version H conversion, this field
was populated with data throughout history (back to
service year 1991) by summing up the line item primary
payer amounts.
DB2 ALIAS : CARR_PRMRY_PYR_AMT
SAS ALIAS : PRPAYAMT
STANDARD ALIAS : CARR_CLM_PRMRY_PYR_PD_AMT
TITLE ALIAS : PRIMARY_PAYER_AMOUNT
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
57. FILLER CHAR
1 240 240
DB2 ALIAS : FILLER
LENGTH : 1
58. Carrier Claim Referring UPIN Number
6 241 246 CHAR
The unique physician identification number
(UPIN) of the physician who referred the
beneficiary to the physician who performed
the Part B services.
COMMON ALIAS : REFERRING_PHYSICIAN_UPIN
DB2 ALIAS : RFRG_UPIN_NUM
SAS ALIAS : RFR_UPIN
STANDARD ALIAS : CARR_CLM_RFRG_UPIN_NUM
TITLE ALIAS : REFERRING_PHYSICIAN_UPIN
LENGTH : 6
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_RFRG_UPIN_NUM.
SOURCE : CWF
59. Carrier Claim Referring Physician NPI Number
10 247 256 CHAR
The national provider identifier (NPI) number
of the physician who referred the beneficiary
to the physician who performed the Part B
services.
NOTE: Effective May 2007, the NPI will be-
come the national standard identifier for
covered health care providers. NPIs will
replace current OSCAR provider number, UPINs,
NSC numbers, and local contractor provider
identification numbers (PINs) on standard
HIPPA claim transactions. (During the NPI
transition phase (4/3/06 - 5/23/07) the
capability was there for the NCH to receive NPIs
along with an existing legacy number (UPIN,
PIN, OSCAR provider number, etc.)).
NOTE1: CMS has determined that dual provider
identifiers (old legacy numbers and new NPI)
must be available on the NCH. After the 5/07
NPI implementation, the standard system main-
tainers will add the legacy number to the claim
when it is adjudicated. We will continue to re-
ceive any currently issued UPINs. Effective May
2007, no new UPINs (legacy number) will be generated
for new physicians (Part B and Outpatient claims)
so there will only be NPIs sent in to the NCH
for those physicians.
DB2 ALIAS : RFRG_PHYSN_NPI_NUM
SAS ALIAS : RFR_NPI
LENGTH : 10
SOURCE : CWF
60. Carrier Claim Provider Assignment Indicator Switch
1 257 257 CHAR
A switch indicating whether or not the provider
accepts assignment for the noninstitutional claim.
DB2 ALIAS : PRVDR_ASGNMT_SW
SAS ALIAS : ASGMNTCD
STANDARD ALIAS : CARR_CLM_PRVDR_ASGNMT_IND_SW
TITLE ALIAS : ASSIGNMENT_SW
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_PRVDR_ASGNMT_IND_SW.
SOURCE : CWF
CODE TABLE : CARR_CLM_PRVDR_ASGNMT_IND_TB
61. NCH Claim Provider Payment Amount
6 258 263 PACK
Effective with Version H, the total payments
made to the provider for this claim (sum of
line item provider payment amounts.)
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : NCH_PRVDR_PMT_AMT
SAS ALIAS : PROV_PMT
STANDARD ALIAS : NCH_CLM_PRVDR_PMT_AMT
TITLE ALIAS : PRVDR_PMT
LENGTH : 9.2 SIGNED : Y
SOURCE : NCH QA Process
62. NCH Claim Beneficiary Payment Amount
6 264 269 PACK
Effective with Version H, the total payments
made to the beneficiary for this claim (sum of
line payment amounts to the beneficiary.)
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : NCH_BENE_PMT_AMT
SAS ALIAS : BENE_PMT
STANDARD ALIAS : NCH_CLM_BENE_PMT_AMT
TITLE ALIAS : BENE_PMT
LENGTH : 9.2 SIGNED : Y
SOURCE : NCH QA Process
63. Carrier Claim Beneficiary Paid Amount
6 270 275 PACK
Effective with Version H, the amount paid by
the beneficiary for the non-institutional Part B
services.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : CARR_BENE_PD_AMT
SAS ALIAS : BENEPAID
STANDARD ALIAS : CARR_CLM_BENE_PD_AMT
TITLE ALIAS : BENE_PD_AMT
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
64. NCH Carrier Claim Submitted Charge Amount
6 276 281 PACK
Effective with Version H, the total submitted
charges on the claim (the sum of line item
submitted charges).
NOTE: During the Version H conversion this field
was populated with data throughout history (back to
service year 1991).
DB2 ALIAS : CARR_SBMT_CHRG_AMT
SAS ALIAS : SBMTCHRG
STANDARD ALIAS : NCH_CARR_SBMT_CHRG_AMT
TITLE ALIAS : SBMT_CHRG
LENGTH : 9.2 SIGNED : Y
SOURCE : NCH QA Process
EDIT RULES :
$$$$$$$$$CC
65. NCH Carrier Claim Allowed Charge Amount
6 282 287 PACK
Effective with Version H, the total allowed
charges on the claim (the sum of line item
allowed charges).
NOTE1: The amount includes beneficiary-paid
amounts (i.e., deductible and coinsurance).
NOTE2: During the Version H conversion this field
was populated with data throughout history (back to
service year 1991).
DB2 ALIAS : CARR_ALOW_CHRG_AMT
SAS ALIAS : ALOWCHRG
STANDARD ALIAS : NCH_CARR_ALOW_CHRG_AMT
TITLE ALIAS : ALOW_CHRG
LENGTH : 9.2 SIGNED : Y
SOURCE : NCH QA Process
EDIT RULES :
$$$$$$$CC
66. Carrier Claim Cash Deductible Applied Amount
6 288 293 PACK
Effective with Version H, the amount of the cash
deductible as submitted on the claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : CASH_DDCTBL_AMT
SAS ALIAS : DEDAPPLY
STANDARD ALIAS : CARR_CLM_CASH_DDCTBL_APPLY_AMT
TITLE ALIAS : CASH_DDCTBL
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
67. Carrier Claim HCPCS Year Code
1 294 294 NUM
Effective with Version H, the terminal digit
of HCPCS version used to code the claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : CARR_HCPCS_YR_CD
SAS ALIAS : HCPCS_YR
STANDARD ALIAS : CARR_CLM_HCPCS_YR_CD
TITLE ALIAS : HCPCS_YR
LENGTH : 1 SIGNED : N
SOURCE : CWF
68. Carrier Claim MCO Override Indicator Code
1 295 295 CHAR
Effective with Version H, the code used to
indicate whether or not an MCO investigation
applies to the claim (used for internal CWFMQA
editing purposes).
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
spaces in this field.
DB2 ALIAS : MCO_OVRRD_IND_CD
SAS ALIAS : MCOOVRRD
STANDARD ALIAS : CARR_CLM_MCO_OVRRD_IND_CD
TITLE ALIAS : MCO_OVERRIDE
LENGTH : 1
SOURCE : CWF
CODE TABLE : CARR_CLM_MCO_OVRRD_IND_TB
69. Carrier Claim Hospice Override Indicator Code
1 296 296 CHAR
Effective with Version H, the code used to
indicate whether or not an Hospice investigation
applies to the claim (used for internal CWFMQA
editing purposes).
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
spaces in this field.
DB2 ALIAS : HOSPC_OVRRD_IND_CD
SAS ALIAS : HOSPOVRD
STANDARD ALIAS : CARR_CLM_HOSPC_OVRRD_IND_CD
TITLE ALIAS : HOSPC_OVERRIDE
LENGTH : 1
SOURCE : CWF
CODE TABLE : CARR_CLM_HOSPC_OVRRD_IND_TB
70. Claim Business Segment Identifier Code
4 297 300 CHAR
Effective 10/1/2005 with the implementation of NCH/NMUD
CR#2, the identifier that captures the 2-byte juris-
diction code (represents the USPS state/territory
abbreviation (i.e. NY = New York) and the 2-byte
modifier that identifies the type of Medicare FFS
contract (intermediary, RHHI, carrier or DMERC).
This 4-byte identifier along with the 5-byte
FI/Carrier number comprises the Contractor
Workload Identifier number. The business segment
identifier (BSI) is intended to help sort work-
loads that may be redistributed with the implemen-
tation of contracting reform as required by MMA.
DB2 ALIAS : BUSNS_SGMT_ID_CD
SAS ALIAS : SGMT_ID
STANDARD ALIAS : CLM_BUSNS_SGMT_ID_CD
LENGTH : 4
SOURCE : CWF
71. Claim Clinical Trial Number
8 301 308 CHAR
Effective September 1, 2008 with the implementation
of CR#3, the number used to identify all items
and services provided to a beneficiary during their
participation in a clinical trial.
NOTE:
CMS is requesting the clinical trial number be
voluntarily reported. The number is assigned by
the National Library of Medicine (NLM) Clinical
Trials Data Bank when a new study is registered.
DB2 ALIAS : CLM_CLNCL_TRIL_NUM
SAS ALIAS : CTRILNUM
LENGTH : 8
72. FILLER CHAR
19 309 327
DB2 ALIAS : FILLER
LENGTH : 19
73. Carrier Specific Group
34 328 361 GRP
This group identifies those fields specific
to the carrier claim record.
74. Carrier Claim Referring PIN Number
14 328 341 CHAR
Carrier-assigned identification (profiling)
number of the physician who referred the
beneficiary to the physician that performed
the Part B services.
COMMON ALIAS : REFERRING_PHYSICIAN_PIN
DB2 ALIAS : RFRG_PIN_NUM
SAS ALIAS : RFR_PRFL
STANDARD ALIAS : CARR_CLM_RFRG_PIN_NUM
TITLE ALIAS : RFRG_PIN
LENGTH : 14
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_RFRG_PHYSN_PRFLG_NUM.
SOURCE : CWF
75. Care Plan Oversight (CPO) Provider Number
6 342 347 CHAR
Effective with NCH weekly process date 3/7/97,
the Medicare provider number of the HHA or Hospice
rendering Medicare covered services during
period the physician is providing care plan
oversight. The purpose of this field is to
ensure compliance with the CPO requirement that
the beneficiary must be receiving covered HHA or
Hospice services during the billing period. There
can be only one CPO provider number per claim, and
no other services but CPO physician services are
to be reported on the claim. This field is only
present on the non-DMERC processed carrier claim.
NOTE: On the Version G format, this field is stored
as a redefinition of the NEAR_LINE_ORGNL_BENE_CAN_NUM
(the first 3 positions contain 'CPO', followed by
the 6-position provider number). During the
Version H conversion the data was moved to this
dedicated field.
DB2 ALIAS : CPO_PRVDR_NUM
SAS ALIAS : CPO_PROV
STANDARD ALIAS : CPO_PRVDR_NUM
LENGTH : 6
SOURCE : CWF
76. CPO Organization NPI Number
10 348 357 CHAR
The National Provider Identifier (NPI) number
of the HHA or Hospice rendering Medicare ser-
vices during the period the physician is pro-
viding care plan oversight. The purpose of
this field is to ensure compliance with the
CPO requirement that the beneficiary must be
receiving covered HHA or Hospice services
during the billing period. There can be only
one CPO provider number per claim, and no
other services but CPO physician services are
to be reported on the claim. This field is only
present on the non-DMERC processed carrier claim.
NOTE: Effective May 2008, the NPI will become the
national standard identifier for covered health
care providers. NPIs will replace the current
legacy provider numbers (UPINs, PINs, OSCAR
provider numbers, etc.) on the standard HIPPA
claim transactions. (During the NPI transition
phase the capability was there for the NCH to receive
NPIs along with an existing legacy number (UPIN, NPIs,
OSCAR provider numbers, etc.)).
NOTE1: CMS has determined that dual provider iden-
tifiers (legacy numbers and NPIs) must be avail-
able on the NCH. After the 5/08 NPI implementation,
the standard system maintainers will add the legacy
number to the claim when it is adjudicated. Effect-
tive May 2008, no NEW UPINs (legacy number) will be
generated for NEW physicians (Part B and Outpatient
claims) so there will only be NPIs sent in to the
NCH for those physicians.
DB2 ALIAS : CPO_ORG_NPI_NUM
SAS ALIAS : CPO_NPI
LENGTH : 10
SOURCE : CWF
77. Claim Blood Pints Furnished Quantity
2 358 359 PACK
Number of whole pints of blood furnished to the
beneficiary, as reported on the carrier claim
(non-DMERC).
DB2 ALIAS : BLOOD_PT_FRNSH_QTY
SAS ALIAS : BLDFRNSH
STANDARD ALIAS : CLM_BLOOD_PT_FRNSH_QTY
TITLE ALIAS : BLOOD_PINTS_FURNISHED
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was stored in a
blood trailer. Version H eliminated the blood
trailer.
SOURCE : CWF
EDIT RULES :
NUMERIC
78. Claim Blood Deductible Pints Quantity
2 360 361 PACK
The quantity of blood pints applied (blood
deductible) as reported on the carrier claim
(non-DMERC).
DB2 ALIAS : BLOOD_DDCTBL_PT
SAS ALIAS : BLD_DED
STANDARD ALIAS : CLM_BLOOD_DDCTBL_PT_QTY
TITLE ALIAS : BLOOD_PINTS_DEDUCTIBLE
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was stored in a
blood trailer. Version H eliminated the blood
trailer.
SOURCE : CWF
EDIT RULES :
NUMERIC
79. Carrier NCH Edit Code Count
2 362 363 NUM
The count of the number of edit codes
annotated to the carrier claim during
HCFA's CWFMQA process. The purpose of
this count is to indicate how many claim
edit trailers are present.
DB2 ALIAS : EDIT_TRLR_CNT
SAS ALIAS : CEDCNT
STANDARD ALIAS : CARR_NCH_EDIT_CD_CNT
LENGTH : 2 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CLM_EDIT_CD_CNT.
SOURCE : NCH
80. Carrier NCH Patch Code Count
2 364 365 NUM
Effective with Version H, the count of the
number of HCFA patch codes annotated to the
carrier claim during the Nearline maintenance
process. The purpose of this count is to
indicate how many NCH patch trailers are
present.
NOTE: During the Version H conversion this
field was populated with data throughout
history (back to service year 1991).
DB2 ALIAS : PATCH_TRLR_CNT
SAS ALIAS : CPATCNT
STANDARD ALIAS : CARR_NCH_PATCH_CD_I_CNT
LENGTH : 2 SIGNED : N
SOURCE : NCH
81. Carrier MCO Period Count
1 366 366 NUM
Effective with Version H, the count of the
number of Managed Care Organization (MCO)
periods reported on a carrier claim.
The purpose of this count is to indicate
how many MCO period trailers are present.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : CARR_MCO_PRD_CNT
SAS ALIAS : CMCOCNT
STANDARD ALIAS : CARR_MCO_PRD_CNT
LENGTH : 1 SIGNED : N
SOURCE : NCH
EDIT RULES :
RANGE: 0 TO 2
82. Carrier Claim Health PlanID Count
1 367 367 NUM
A placeholder field (effective with Version H)
for storing the count of the number of Health
PlanIDs reported on the carrier claim. The
purpose of this count is to indicate how many
Health PlanID trailers are present. NOTE: Prior
to Version 'I' this field was named:
CARR_CLM_PAYERID_CNT.
DB2 ALIAS : PAYERID_TRLR_CNT
SAS ALIAS : CPLNCNT
STANDARD ALIAS : CARR_CLM_HLTH_PLANID_CNT
LENGTH : 1 SIGNED : N
SOURCE : NCH
EDIT RULES :
RANGE: 0 TO 3
83. Carrier Claim Demonstration ID Count
1 368 368 NUM
Effective with Version H, the count of the number
of claim demonstration IDs reported on an
carrier claim. The purpose of this count is
to indicate how many claim demonstration
trailers are present.
NOTE: During the Version H conversion this field
was populated with data where a demo was
identifiable.
DB2 ALIAS : DEMO_TRLR_CNT
SAS ALIAS : CDEMCNT
STANDARD ALIAS : CARR_CLM_DEMO_ID_CNT
LENGTH : 1 SIGNED : N
SOURCE : NCH
EDIT RULES :
RANGE: 0 TO 5
84. Carrier Claim Diagnosis Code Count
1 369 369 NUM
The count of the number of diagnosis codes (both
principal and other) reported on an carrier
claim. The purpose of this count is to indicate
how many claim diagnosis trailers are present.
DB2 ALIAS : DGNS_TRLR_CNT
SAS ALIAS : CDGNCNT
STANDARD ALIAS : CARR_CLM_DGNS_CD_CNT
LENGTH : 1 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CLM_DGNS_CD_CNT.
SOURCE : NCH
EDIT RULES :
RANGE: 0 TO 4
85. Carrier Claim Line Count
2 370 371 NUM
The count of the number of line items reported
on the carrier claim. The purpose of this count
is to indicate how many line item trailers are
present.
DB2 ALIAS : LINE_ITM_TRLR_CNT
SAS ALIAS : CLINECNT
STANDARD ALIAS : CARR_CLM_LINE_CNT
LENGTH : 2 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CWFB_CLM_NUM_LINE_ITM_CNT.
SOURCE : CWFB CLAIMS
EDIT RULES :
RANGE: 1 TO 13
86. FILLER CHAR
4 372 375
DB2 ALIAS : FILLER
LENGTH : 4
87. Carrier Claim Variable Group
VAR 376 4863 GRP
Variable portion of the carrier claim record
for version I of the NCH.
88. NCH Edit Group
5 376 380 GRP
The number of claim edit trailers is determined
by the claim edit code count.
STANDARD ALIAS : NCH_EDIT_GRP
OCCURS MIN: 0 OCCURS MAX: 13
DEPENDING ON : CARR_NCH_EDIT_CD_CNT
89. NCH Edit Trailer Indicator Code
1 376 376 CHAR
Effective with Version H, the code indicating
the presence of an NCH edit trailer.
NOTE: During the Version H conversion this field
was populated throughout history (back to service
year 1991).
DB2 ALIAS : EDIT_TRLR_IND_CD
SAS ALIAS : EDITIND
STANDARD ALIAS : NCH_EDIT_TRLR_IND_CD
LENGTH : 1
SOURCE : NCH QA Process
CODE TABLE : NCH_EDIT_TRLR_IND_TB
90. NCH Edit Code
4 377 380 CHAR
The code annotated to the claim indicating
the CWFMQA editing results so users will
be aware of data deficiencies.
NOTE: Prior to Version H only the highest
priority code was stored. Beginning 11/98
up to 13 edit codes may be present.
COMMON ALIAS : QA_ERROR_CODE
DB2 ALIAS : NCH_EDIT_CD
SAS ALIAS : EDIT_CD
STANDARD ALIAS : NCH_EDIT_CD
TITLE ALIAS : QA_ERROR_CD
LENGTH : 4
SOURCE : NCH QA EDIT PROCESS
CODE TABLE : NCH_EDIT_TB
91. NCH Patch Group
11 1 11 GRP
STANDARD ALIAS : NCH_PATCH_GRP
OCCURS MIN: 0 OCCURS MAX: 30
DEPENDING ON : CARR_NCH_PATCH_CD_I_CNT
92. NCH Patch Trailer Indicator Code
1 1 1 CHAR
Effective with Version H, the code indicating
the presence of an NCH patch trailer.
NOTE: During the Version H conversion this field
was populated throughout history (back to service
year 1991).
DB2 ALIAS : PATCH_TRLR_IND_CD
SAS ALIAS : PATCHIND
STANDARD ALIAS : NCH_PATCH_TRLR_IND_CD
LENGTH : 1
SOURCE : NCH
CODE TABLE : NCH_PATCH_TRLR_IND_TB
93. NCH Patch Code
2 2 3 CHAR
Effective with Version H, the code annotated
to the claim indicating a patch was applied
to the record during an NCH Nearline record
conversion and/or during current processing.
NOTE: Prior to Version H this field was located
in the third and fourth occurrence of the
CLM_EDIT_CD.
DB2 ALIAS : NCH_PATCH_CD
SAS ALIAS : PATCHCD
STANDARD ALIAS : NCH_PATCH_CD
TITLE ALIAS : NCH_PATCH
LENGTH : 2
SOURCE : NCH
CODE TABLE : NCH_PATCH_TB
94. NCH Patch Applied Date
8 4 11 NUM
Effective with Version H, the date the NCH patch
was applied to the claim.
DB2 ALIAS : NCH_PATCH_APPLY_DT
SAS ALIAS : PATCHDT
STANDARD ALIAS : NCH_PATCH_APPLY_DT
TITLE ALIAS : NCH_PATCH_DT
LENGTH : 8 SIGNED : N
SOURCE : NCH
EDIT RULES :
YYYYMMDD
95. MCO Period Group
37 1 37 GRP
The number of managed care organization (MCO)
period data trailers present is determined by
the claim MCO period trailer count. This field
reflects the two most current MCO periods in the
CWF beneficiary history record. It may have no
connection to the services on the claim.
STANDARD ALIAS : MCO_PRD_GRP
OCCURS MIN: 0 OCCURS MAX: 2
DEPENDING ON : CARR_MCO_PRD_CNT
96. NCH MCO Trailer Indicator Code
1 1 1 CHAR
Effective with Version H, the code indicating
the presence of a Managed Care Organization (MCO)
trailer.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
spaces in this field.
COBOL ALIAS : MCO_IND
DB2 ALIAS : MCO_TRLR_IND_CD
SAS ALIAS : MCOIND
STANDARD ALIAS : NCH_MCO_TRLR_IND_CD
TITLE ALIAS : MCO_INDICATOR
LENGTH : 1
SOURCE : NCH QA Process
CODE TABLE : NCH_MCO_TRLR_IND_TB
97. MCO Contract Number
5 2 6 CHAR
Effective with Version H, this field represents
the plan contract number of the Managed Care
Organization (MCO).
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
spaces in this field.
DB2 ALIAS : MCO_CNTRCT_NUM
SAS ALIAS : MCONUM
STANDARD ALIAS : MCO_CNTRCT_NUM
TITLE ALIAS : MCO_NUM
LENGTH : 5
SOURCE : CWF
98. MCO Option Code
1 7 7 CHAR
Effective with Version H, the code indicating
Managed Care Organization (MCO) lock-in
enrollment status of the beneficiary.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
spaces in this field.
DB2 ALIAS : MCO_OPTN_CD
SAS ALIAS : MCOOPTN
STANDARD ALIAS : MCO_OPTN_CD
TITLE ALIAS : MCO_OPTION_CD
LENGTH : 1
SOURCE : CWF
CODE TABLE : MCO_OPTN_TB
99. MCO Period Effective Date
8 8 15 NUM
Effective with Version H, the date the bene-
ficiary's enrollment in the Managed Care
Organization (MCO) became effective.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : MCO_PRD_EFCTV_DT
SAS ALIAS : MCOEFFDT
STANDARD ALIAS : MCO_PRD_EFCTV_DT
TITLE ALIAS : MCO_PERIOD_EFF_DT
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
100. MCO Period Termination Date
8 16 23 NUM
Effective with Version H, the date the bene-
ficiary's enrollment in the Managed Care
Organization (MCO) was terminated.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : MCO_PRD_TRMNTN_DT
SAS ALIAS : MCOTRMDT
STANDARD ALIAS : MCO_PRD_TRMNTN_DT
TITLE ALIAS : MCO_PERIOD_TERM_DT
LENGTH : 8 SIGNED : N
SOURCE : CWF
EDIT RULES :
YYYYMMDD
101. MCO Health PLANID Number
14 24 37 CHAR
A placeholder field (effective with Version H)
for storing the Health PlanID associated with
the Managed Care Organization (MCO). Prior to
Version 'I' this field was named:
MCO_PAYERID_NUM.
DB2 ALIAS : MCO_PLANID_NUM
SAS ALIAS : MCOPLNID
STANDARD ALIAS : MCO_HLTH_PLANID_NUM
TITLE ALIAS : MCO_PLANID
LENGTH : 14
COMMENTS :
Prior to Version I this field was named:
MCO_PAYERID_NUM.
SOURCE : CWF
102. Claim Health PlanID Group
16 1 16 GRP
The number of Health PlanID data trailers is determined
by the claim Health PlanID trailer count. Prior
to Version 'I' this field was named:
CLM_PAYERID_GRP.
STANDARD ALIAS : CLM_HLTH_PLANID_GRP
OCCURS MIN: 0 OCCURS MAX: 3
DEPENDING ON : CARR_CLM_HLTH_PLANID_CNT
103. NCH Health PlanID Trailer Indicator Code
1 1 1 CHAR
A placeholder field (effective with Version H)
for storing the code that indicates the presence
of a Health PlanID trailer. NOTE: Prior to
Version 'I' this field was named:
NCH_PAYERID_TRLR_IND_CD.
DB2 ALIAS : NCH_HLTH_PLANID_TR
SAS ALIAS : PLANIDIN
STANDARD ALIAS : NCH_HLTH_PLANID_TRLR_IND_CD
LENGTH : 1
COMMENTS :
Prior to Version I this field was named:
NCH_PAYERID_TRLR_IND_CD.
SOURCE : NCH
CODE TABLE : NCH_HLTH_PLANID_TRLR_IND_TB
104. Claim Health PlanID Code
1 2 2 CHAR
A placeholder field (effective with Version H)
for storing the code identifying the type of
Health PlanID. Prior to Version 'I' this field
was named: CLM_PAYERID-CD
DB2 ALIAS : HLTH_PLANID_CD
SAS ALIAS : PLANIDCD
STANDARD ALIAS : CLM_HLTH_PLANID_CD
TITLE ALIAS : PLANID_TYPE
LENGTH : 1
COMMENTS :
Prior to Version I this field was named:
CLM_PAYERID_CD.
SOURCE : CWF
CODE TABLE : CLM_HLTH_PLANID_TB
105. Claim Health PlanID Number
14 3 16 CHAR
A placeholder field (effective with Version H)
for storing the Health PlanID number. Prior
to Version 'I' this field was named:
CLM_PAYERID_NUM.
DB2 ALIAS : HLTH_PLANID_NUM
SAS ALIAS : PLANID
STANDARD ALIAS : CLM_HLTH_PLANID_NUM
TITLE ALIAS : PLANID
LENGTH : 14
COMMENTS :
Prior to Version I this field was named:
CLM_PAYERID_NUM.
SOURCE : CWF
106. Claim Demonstration Identification Group
18 1 18 GRP
The number of demonstration identification
trailers present is determined by the claim
demonstration identification trailer count.
STANDARD ALIAS : CLM_DEMO_ID_GRP
OCCURS MIN: 0 OCCURS MAX: 5
DEPENDING ON : CARR_CLM_DEMO_ID_CNT
107. NCH Demonstration Trailer Indicator Code
1 1 1 CHAR
Effective with Version H, the code indicating
the presence of a demo trailer.
NOTE: During the Version H conversion this field
was populated throughout history (back to service
year 1991).
COBOL ALIAS : DEMO_IND
DB2 ALIAS : NCH_DEMO_TRLR_IND_
SAS ALIAS : DEMOIND
STANDARD ALIAS : NCH_DEMO_TRLR_IND_CD
TITLE ALIAS : DEMO_INDICATOR
LENGTH : 1
SOURCE : NCH
CODE TABLE : NCH_DEMO_TRLR_IND_TB
108. Claim Demonstration Identification Number
2 2 3 CHAR
Effective with Version H, the number assigned
to identify a demo. This field is also used to
denote special processing (a.k.a. Special Processing
Number, SPN).
NOTE: Prior to Version H, Demo ID was stored in the
redefined Claim Edit Group, 4th occurrence, positions
3 and 4. During the H conversion, this field was
populated with data throughout history (as appro-
private either by moving ID on Version G or by
deriving from specific demo criteria).
01 = Nursing Home Case-Mix and Quality: NHCMQ
(RUGS) Demo -- testing PPS for SNFs in 6
states, using a case-mix classification
system based on resident characteristics and
actual resources used. The claims carry a
RUGS indicator and one or more revenue center
codes in the 9,000 series.
NOTE1: Effective for SNF claims with NCH weekly
process date after 2/8/96 (and service date after
12/31/95) -- beginning 4/97, Demo ID '01' was
derived in NCH based on presence of RUGS phase #
'2','3' or '4' on incoming claim; since 7/97, CWF
has been adding ID to claim.
NOTE2: During the Version H conversion, Demo ID
'01' was populated back to NCH weekly process date
2/9/96 based on the RUGS phase indicator (stored
in Claim Edit Group, 3rd occurrence, 4th position,
in Version G).
02 = National HHA Prospective Payment Demo --
testing PPS for HHAs in 5 states, using two
alternate methods of paying HHAs: per visit
by type of HHA visit and per episode of HH
care.
NOTE1: Effective for HHA claims with NCH weekly
process date after 5/31/95 -- beginning 4/97,
Demo ID '02' was derived in NCH based on HCFA/
CHPP-supplied listing of provider # and start/
stop dates of participants.
NOTE2: During the Version H conversion, Demo ID
'02' was populated back to NCH weekly process
date 6/95 based on the CHPP criteria.
03 = Telemedicine Demo -- testing covering tradi-
tionally noncovered physician services for
medical consultation furnished via two-way, inter-
active video systems (i.e. teleconsultation)
in 4 states. The claims contain line items
with 'QQ' HCPCS code.
NOTE1: Effective for physician/supplier (nonDMERC)
claims with NCH weekly process date after 12/31/96
(and service date after 9/30/96) -- since 7/97,
CWF has been adding Demo ID '03' to claim.
NOTE2: During Version H conversion, Demo ID '03'
was populated back to NCH weekly process date 1/97
based on the presence of 'QQ' HCPCS on one or more
line items.
04 = United Mine Workers of America (UMWA) Managed
Care Demo -- testing risk sharing for Part A
services, paying special capitation rates for
all UMWA beneficiaries residing in 13 desig-
nated counties in 3 states. Under the demo,
UMWA will waive the 3-day qualifying hospital
stay for a SNF admission. The claims contain
TOB '18X','21X','28X' and '51X'; condition
code = W0; claim MCO paid switch = not '0';
and MCO contract # = '90091'.
NOTE: Initially scheduled to be implemented for
all SNF claims for admission or services on
1/1/97 or later, CWF did not transmit any Demo
ID '04' annotated claims until on or about 2/98.
05 = Medicare Choices (MCO encounter data) demo --
testing expanding the type of Managed Care
plans available and different payment methods
at 16 MCOs in 9 states. The claims contain
one of the specific MCO Plan Contract #
assigned to the Choices Demo site.
NOTE1: Effective for all claim types with NCH
weekly process date after 7/31/97 -- CWF adds
Demo ID '05' to claim based on the presence of
the MCO Plan Contract #. ***Demonstration was
terminated 12/31/2000.***
NOTE2: During the Version H conversion, Demo ID
'05' was populated back to NCH weekly process
date 8/97 based on the presence of the Choices
indicator (stored as an alpha character cross-
walked from MCO plan contract # in the Claim
Edit Group, 4th occurrence, 2nd position, in
Version 'G').
06 = Coronary Artery Bypass Graft (CABG) Demo --
testing bundled payment (all-inclusive global
pricing) for hospital + physician services
related to CABG surgery in 7 hospitals in 7
states. The inpatient claims contain a DRG
'106' or '107'.
NOTE1: Effective for Inpatient claims and
physician/supplier claims with Claim Edit Date
no earlier than 6/1/91 (not all CABG sites
started at the same time) -- on 5/1/97, CWF
started transmitting Demo ID '06' on the claim.
The FI adds the ID to the claim based on the
presence of DRG '106' or '107' from specific
providers for specified time periods; the
carrier adds the ID to the claim based on
receiving 'Daily Census List' from parti-
cipating hospitals. ***Demo terminated in
1998.***
NOTE2: During the Version H conversion, any
claims where Medicare is the primary payer
that were not already identified as Demo ID
'06' (stored in the redefined Claim Edit
Group, 4th occurrence, positions 3 and 4,
Version G) were annotated based on the follow-
ing criteria: Inpatient - presence of DRG '106'
or '107' and a provider number=220897, 150897,
380897,450897,110082,230156 or 360085 for
specified service dates; noninstitutional -
presence of HCPCS modifier (initial and/or
second) = 'Q2' and a carrier number =00700/31143
00630,01380,00900,01040/00511,00710,00623, or
13630 for specified service dates.
07 = Virginia Cardiac Surgery Initiative (VCSI)
(formerly referred to as Medicare Quality Partner-
ships Demo) -- this is a voluntary consortium of
the cardiac surgery physician groups and the non-
Veterans Administration hospitals providing open
heart surgical services in the Commonwealth of
Virginia. The goal of the demo is to share data on
quality and process innovations in an attempt to
improve the care for all cardiac patients. The
demonstration only affects those FIs that process
claims from hospitals in Virginia and the carriers
that process claims from physicians providing
inpatient services at those hospitals. The
hospitals will be reimbursed on a global payment
basis for selected cardiac surgical diagnosis
related groups (DRGs). The inpatient claims will
contain a DRG '104', '105', '106', '107', '109';
the related physician/supplier claims will contain
the claim payment denial reason code = 'D'.
NOTE: The implementation date for this demo is 4/1/03.
The FI will annotate the claim with the demo id
add Demo ID '07' to claim. For carrier claims, the
Standard Systems will annotate the claim with the
'07' demo number.
08 = Provider Partnership Demo -- testing per-case
payment approaches for acute inpatient
hospitalizations, making a lump-sum payment
(combining the normal Part A PPS payment with
the Part B allowed charges into a single fee
schedule) to a Physician/Hospital Organization
for all Part A and Part B services associated
with a hospital admission. From 3 to 6 hospitals
in the Northeast and Mid-Atlantic regions may
participate in the demo.
NOTE: The demo is on HOLD. The FI and carrier will
add Demo ID '08' to claim.
15 = ESRD Managed Care (MCO encounter data) --
testing open enrollment of ESRD beneficiaries
and capitation rates adjusted for patient
treatment needs at 3 MCOs in 3 States. The
claims contain one of the specific MCO Plan
Contract # assigned to the ESRD demo site.
NOTE: Effective 10/1/97 (but not actually imple-
mented at a site until 1/1/98) for all claim
types -- the FI and carrier add Demo ID '15' to
claim based on the presence of the MCO plan
contract #.
30 = Lung Volume Reduction Surgery (LVRS) or
National Emphysema Treatment Trial (NETT)
Clinical Study -- evaluating the effective-
ness of LVRS and maximum medical therapy (in-
cluding pulmonary rehab) for Medicare bene-
ficiaries in last stages of emphysema at 18
hospitals nationally, in collaboration with
NIH.
NOTE: Effective for all claim types (except DMERC)
with NCH weekly process date after 2/27/98 (and
service date after 10/31/97) -- the FI adds Demo ID
'30' based on the presence of a condition code = EY;
the participating physician (not the carrier) adds
ID to the noninstitutional claim. DUE TO THE SEN-
SITIVE NATURE OF THIS CLINICAL TRIAL AND UNDER THE
TERMS OF THE INTERAGENCY AGREEMENT WITH NIH, THESE
CLAIMS ARE PROCESSED BY CWF AND TRANSMITTED TO
HCFA BUT NOT STORED IN THE NEARLINE FILE (access
is restricted to study evaluators only).
31 = VA Pricing Special Processing (SPN) -- not really
a demo but special request from VA due to
court settlement; not Medicare services but
VA inpatient and physician services submitted
to FI 00400 and Carrier 00900 to obtain
Medicare pricing -- CWF WILL PROCESS VA
CLAIMS ANNOTATED WITH DEMO ID '31', BUT WILL
NOT TRANSMIT TO HCFA (not in Nearline File).
37 = Medicare Coordinated Care Demonstration -- to test
whether coordinated care services furnished to
certain beneficiaries improves outcome of care
and reduces Medicare expenditures under Part A and
Part B. There will be at least 14 Coordinated
Care Entities (CCEs). The selected entities will
be assigned a provider number specifically for the
demonstration services.
NOTE: All claims will be processed by carriers;
no FI processing (except for Georgetown site)
37 = Medicare Disease Management (DMD) -- the purpose
of this demonstration is to study the impact on costs
and health outcomes of applying disease management
services supplemented with coverage for prescription
drugs for certain Medicare beneficiaries with diag-
nosed, advanced-stage congestive heart failure,
diabetes, or coronary heart disease. Three demon-
stration sites will be used for this demonstration
and it will last for 3 years. (Effective 4/1/2003).
NOTE: All claims will be processed by NHIC-California
(Carrier). FIs will only serve as a conduit for trans-
mitting information to and from CWF about the NOEs.
38 = Physician Encounter Claims - the purpose of this
demo id is to identify the physician encounter
claims being processed at the HCFA Data Center (HDC).
This number will help EDS in making the claim go
through the appropriate processing logic, which
differs from that for fee-for-service. **NOT
IN NCH.**
NOTE: Effective October, 2000. Demo ids will not be
assigned to Inpatient and Outpatient encounter claims.
39 = Centralized Billing of Flu and PPV Claims -- The
purpose of this demo is to facilitate the processing
carrier, Trailblazers, paying flu and PPV claims
based on payment localities. Providers will be
giving the shots throughout the country and trans-
mitting the claims to Trailblazers for processing.
NOTE: Effective October, 2000 for carrier claims.
40 = Payment of Physician and Nonphysician Services
in certain Indian Providers -- the purpose of
this demo is to extend payment for services of
physician and nonphysician practitioners
furnished in hospitals and ambulatory care clinics.
Prior to the legislation change in BIPA, reim-
bursement for Medicare services provided in IHS
facilities was limited to services provided in
hospitals and skilled nursing facilities. This
change will allow payment for IHS, Tribe and
Tribal Organization providers under the Medicare
physician fee schedule.
NOTE: Effective July 1, 2001 for institutional and
carrier claims.
48 = Medical Adult Day-Care Services -- the purpose
of this demonstration is to provide, as part of the
episode of care for home health services, medical
adult day care services to Medicare beneficiaries as
a substitute for a portion of home health services
that would otherwise be provided in the beneficiaries
home. This demo would last approx. 3 years in not
more than 5 sites. Payment for each home health ser-
vice episode of care will be set at 95% of the amount
that would otherwise be paid for home health services
provided entirely in the home.
NOTE: Effective July 5, 2005 for HHA claims.
DB2 ALIAS : CLM_DEMO_ID_NUM
SAS ALIAS : DEMONUM
STANDARD ALIAS : CLM_DEMO_ID_NUM
TITLE ALIAS : DEMO_ID
LENGTH : 2
SOURCE : CWF
109. Claim Demonstration Information Text
15 4 18 CHAR
Effective with Version H, the text field that
contains related demo information. For example,
a claim involving a CHOICES demo id '05' would
contain the MCO plan contract number in the first
five positions of this text field.
NOTE: During the Version H conversion this
field was populated with data throughout
history.
DB2 ALIAS : CLM_DEMO_INFO_TXT
SAS ALIAS : DEMOTXT
STANDARD ALIAS : CLM_DEMO_INFO_TXT
TITLE ALIAS : DEMO_INFO
LENGTH : 15
DERIVATIONS :
DERIVATION RULES:
Demo ID = 01 (RUGS) -- the text field will contain
a 2, 3 or 4 to denote the RUGS phase. If RUGS phase
is blank or not one of the above the text field
will reflect 'INVALID'. NOTE: In Version 'G', RUGS
phase was stored in redefined Claim Edit Group,
3rd occurrence, 4th position.
Demo ID = 02 (Home Health demo) -- the text field
will contain PROV#. When demo number not equal to
02 then text will reflect 'INVALID'.
Demo ID = 03 (Telemedicine demo) -- text field will
contain the HCPCS code. If the required HCPCS is
not shown then the text field will reflect
'INVALID'.
Demo ID = 04 (UMWA) -- text field will contain
W0 denoting that condition code W0 was present.
If condition code W0 not present then the text
field will reflect 'INVALID'.
Demo ID = 05 (CHOICES) -- the text field will con-
tain the CHOICES plan number, if both of the follow-
ing conditions are met: (1) CHOICES plan number
present and PPS or Inpatient claim shows that 1st
3 positions of provider number as '210' and the
admission date is within HMO effective/termination
date; or non-PPS claim and the from date is within
HMO effective/termination date and (2) CHOICES
plan number matches the HMO plan number. If
either condition is not met the text field will
reflect 'INVALID CHOICES PLAN NUMBER'. When
CHOICES plan number not present, text will re-
flect 'INVALID'.
NOTE: In Version 'G', a valid CHOICES plan ID is
stored as alpha character in redefined Claim
Edit Group, 4th occurrence, 2nd position. If
invalid, CHOICES indicator 'ZZ' displayed.
Demo ID = 15 (ESRD Managed Care) -- text field
will contain the ESRD/MCO plan number. If ESRD/
MCO plan number not present the field will
reflect 'INVALID'.
Demo ID = 38 (Physician Encounter Claims) --
text field will contain the MCO plan number.
When MCO plan number not present the field will
reflect 'INVALID'.
SOURCE : CWF
LIMITATIONS :
REFER TO :
CHOICES_DEMO_LIM
110. Carrier Claim Diagnosis Group
7 1 7 GRP
OCCURS MIN: 0 OCCURS MAX: 8
DEPENDING ON : CARR_CLM_DGNS_CD_CNT
111. NCH Diagnosis Trailer Indicator Code
1 1 1 CHAR
Effective with Version H, the code indicating
the presence of a diagnosis trailer.
NOTE: During the Version H conversion this field
was populated throughout history (back to service
year 1991).
DB2 ALIAS : DGNS_TRLR_IND_CD
SAS ALIAS : DGNSIND
STANDARD ALIAS : NCH_DGNS_TRLR_IND_CD
LENGTH : 1
SOURCE : NCH
CODE TABLE : NCH_DGNS_TRLR_IND_TB
112. Claim Diagnosis Code
5 2 6 CHAR
The ICD-9-CM based code identifying the
beneficiary's principal or other diagnosis
(including E code).
NOTE:
Prior to Version H, the principal diagnosis
code was not stored with the 'OTHER' diagnosis
codes. During the Version H conversion the
CLM_PRNCPAL_DGNS_CD was added as the first
occurrence.
DB2 ALIAS : CLM_DGNS_CD
SAS ALIAS : DGNS_CD
STANDARD ALIAS : CLM_DGNS_CD
TITLE ALIAS : DIAGNOSIS
LENGTH : 5
COMMENTS :
Prior to Version H this field was named:
CLM_OTHR_DGNS_CD.
EDIT RULES :
ICD-9-CM
113. FILLER CHAR
1 7 7
DB2 ALIAS : FILLER
LENGTH : 1
114. Carrier Line Item Group
294 1 294 GRP
The line item trailer group may occur
multiple times in one carrier claim. Up to 13
occurrences may be present.
OCCURS MIN: 1OCCURS MAX: 13
DEPENDING ON : CARR_CLM_LINE_CNT
115. NCH Line Item Trailer Indicator Code
1 1 1 CHAR
Effective with Version H, the code indicating
the presence of a line item trailer on the non-
institutional claim.
NOTE: During the Version H conversion this field
was populated throughout history (back to service
year 1991).
DB2 ALIAS : LINE_TRLR_IND_CD
SAS ALIAS : LINEIND
STANDARD ALIAS : NCH_LINE_TRLR_IND_CD
LENGTH : 1
SOURCE : NCH
CODE TABLE : NCH_LINE_TRLR_IND_TB
116. Carrier Line Performing PIN Number
10 2 11 CHAR
The profiling identification number (PIN) of the
physician\supplier (assigned by the carrier) who
performed the service for this line item on the
carrier claim (non-DMERC).
COMMON ALIAS : PHYSICIAN/SUPPLIER_PROVIDER_NUM
DB2 ALIAS : LINE_PRFRMG_PIN
SAS ALIAS : PRF_PRFL
STANDARD ALIAS : CARR_LINE_PRFRMG_PIN_NUM
TITLE ALIAS : PRFRMG_PIN
LENGTH : 10
COMMENTS :
Prior to Version H this field was named:
CWFB_PRFRMG_PRVDR_PRFLG_NUM.
SOURCE : CWF
117. Carrier Line Performing UPIN Number
6 12 17 CHAR
The unique physician identification number
(UPIN) of the physician who performed the
service for this line item on the carrier
claim (non-DMERC).
DB2 ALIAS : LINE_PRFRMG_UPIN
SAS ALIAS : PRF_UPIN
STANDARD ALIAS : CARR_LINE_PRFRMG_UPIN_NUM
TITLE ALIAS : PRFRMG_UPIN
LENGTH : 6
COMMENTS :
Prior to Version H this field was named:
CWFB_PRFRMG_PRVDR_UPIN_NUM.
SOURCE : CWF
LIMITATIONS :
REFER TO :
CARR_LINE_PRFRMG_UPIN_LIM
118. Carrier Line Performing NPI Number
10 18 27 CHAR
A placeholder field (effective with Version H)
for storing the NPI assigned to the performing
provider.
DB2 ALIAS : LINE_PRFRMG_NPI
SAS ALIAS : PRFNPI
LENGTH : 10
SOURCE : CWF
119. Carrier Line Performing Group NPI Number
10 28 37 GRP
CHAR
The National Provider Identifier (NPI) of the
group practice, where the performing physician
is part of that group.
NOTE: Effective May 2007, the NPI will become
the national standard identifier for covered
health care providers. NPIs will replace the
current legacy numbers (UPINs, PINs, etc.) on
the standard HIPPA claim transactions. (During
the NPI transition phase (4/3/06 - 5/23/07) the
capability was there for the NCH to receive NPIs
along with an existing legacy number.
CMS has determined that dual provider identifiers
(old legacy numbers and new NPI) must be available
in the NCH. After the 5/07 NPI implementation, the
standard system maintainers will add the legacy
number to the claim when it is adjudicated. We
will continue to receive the OSCAR provider
number and any currently issued UPINs. Effective
May 2007, no NEW UPINs (legacy number) will be
generated for NEW physicians (Part B and Outpatient
claims), so there will only be NPIs sent in to the
NCH for those physicians.
DB2 ALIAS : PRFRMG_GRP_NPI
SAS ALIAS : PRGRPNPI
LENGTH : 10
SOURCE : CWF
120. Carrier Line Provider Type Code
1 38 38 CHAR
Code identifying the type of provider
furnishing the service for this line item
on the carrier claim (non-DMERC).
DB2 ALIAS : LINE_PRVDR_TYPE_CD
SAS ALIAS : PRV_TYPE
STANDARD ALIAS : CARR_LINE_PRVDR_TYPE_CD
TITLE ALIAS : PRVDR_TYPE
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_PRVDR_TYPE_CD.
SOURCE : CWF
CODE TABLE : CARR_LINE_PRVDR_TYPE_TB
121. Line Provider Tax Number
10 39 48 CHAR
Social security number or employee
identification number of physician/supplier
used to identify to whom payment is made for
the line item service on the noninstitutional
claim.
DB2 ALIAS : LINE_PRVDR_TAX_NUM
SAS ALIAS : TAX_NUM
STANDARD ALIAS : LINE_PRVDR_TAX_NUM
TITLE ALIAS : PRVDR_TAX_NUM
LENGTH : 10
COMMENTS :
Prior to Version H this field was named:
CWFB_PRVDR_TAX_NUM.
SOURCE : NCH
122. Line NCH Provider State Code
2 49 50 CHAR
Effective with Version H, the two position
SSA state code where provider facility is
located.
NOTE: During the Version H conversion this field
was populated with data throughout history (back
to service year 1991).
DB2 ALIAS : LINE_PRVDR_STATE
SAS ALIAS : PRVSTATE
STANDARD ALIAS : LINE_NCH_PRVDR_STATE_CD
TITLE ALIAS : PRVDR_STATE
LENGTH : 2
DERIVATIONS :
DERIVED FROM:
CARR_LINE_PRFRMG_PRVDR_ZIP_CD
DERIVATION RULES:
Use the first three positions of the provider
zip code to derive the LINE_NCH_PRVDR_STATE_CD
from a crosswalk file. Where a match is not
achieved this field will be blank.
SOURCE : NCH
CODE TABLE : GEO_SSA_STATE_TB
123. Carrier Line Performing Provider ZIP Code
9 51 59 CHAR
The ZIP code of the physician/supplier who
performed the Part B service for this line
item on the carrier claim (non-DMERC).
DB2 ALIAS : LINE_PRVDR_ZIP_CD
SAS ALIAS : PROVZIP
STANDARD ALIAS : CARR_LINE_PRFRMG_PRVDR_ZIP_CD
TITLE ALIAS : PRVDR_ZIP_CD
LENGTH : 9
COMMENTS :
Prior to Version H this field was named:
CWFB_PRFRMG_PRVDR_ZIP_CD and the field size
was S9(9).
SOURCE : CWF
124. Line HCFA Provider Specialty Code
2 60 61 CHAR
CMS specialty code used for pricing the
line item service on the noninstitutional
claim.
DB2 ALIAS : HCFA_SPCLTY_CD
SAS ALIAS : HCFASPCL
STANDARD ALIAS : LINE_HCFA_PRVDR_SPCLTY_CD
TITLE ALIAS : HCFA_PRVDR_SPCLTY
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CWFB_HCFA_PRVDR_SPCLTY_CD.
SOURCE : CWF
CODE TABLE : HCFA_PRVDR_SPCLTY_TB
125. Carrier Line Provider Specialty Code
2 62 63 CHAR
The carrier's specialty code for the provider
(usually different from HCFA's) used for
pricing the service for this line item on
the carrier claim (non-DMERC).
NOTE: The LINE_HCFA_PRVDR_SPCLTY_CD is the code to use,
This code is an hold over field from the days before the
Physician Fee Schedule was implemented. CMS allowed
carriers to have their own set of codes for developing
local pricing profiles, i.e. prevailing charge, customary
charge, or reasonable charge systems. Physician services
are no longer priced using this method. Some carriers
still maintain these local specialties but they are NOT
recognized by CMS.
It has been determined that this field is useless for
national pricing or statistics. CWF systems still allows
this field and passes the data (if submitted) on to the
NCH.
DB2 ALIAS : PRVDR_SPCLTY_CD
SAS ALIAS : CARRSPCL
STANDARD ALIAS : CARR_LINE_PRVDR_SPCLTY_CD
TITLE ALIAS : CARR_PRVDR_SPCLTY
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CWFB_CARR_PRVDR_SPCLTY_CD.
SOURCE : CWF
EDIT RULES :
CARRIER INFORMATION FILE
126. Line Provider Participating Indicator Code
1 64 64 CHAR
Code indicating whether or not a provider is
participating or accepting assignment for this
line item service on the noninstitutional claim.
DB2 ALIAS : PRVDR_PRTCPTG_CD
SAS ALIAS : PRTCPTG
STANDARD ALIAS : LINE_PRVDR_PRTCPTG_IND_CD
TITLE ALIAS : PRVDR_PRTCPTG_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_PRVDR_PRTCPTG_IND_CD.
SOURCE : CWF
CODE TABLE : LINE_PRVDR_PRTCPTG_IND_TB
127. Carrier Line Reduced Payment Physician Assistant Code
1 65 65 CHAR
Effective 1/92, the code on the carrier (non-DMERC)
line item that identifies claims that have been
paid a reduced fee schedule amount (65%, 75% or 85%)
because a physician's assistant performed the
services.
COMMON ALIAS : PA_65/75/85%_FEE
DB2 ALIAS : PHYSN_ASTNT_CD
SAS ALIAS : ASTNT_CD
STANDARD ALIAS : CARR_LINE_RDCD_PHYSN_ASTNT_CD
TITLE ALIAS : PHYSN_ASTNT_CD
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_RDCD_PMT_PHYSN_ASTNT_CD.
SOURCE : CWF
CODE TABLE : CARR_LINE_RDCD_PHYSN_ASTNT_TB
128. Line Service Count
2 66 67 PACK
The count of the total number of services
processed for the line item on the non-institutional
claim.
DB2 ALIAS : SRVC_CNT
SAS ALIAS : SRVC_CNT
STANDARD ALIAS : LINE_SRVC_CNT
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_SRVC_CNT.
SOURCE : CWF
129. Line HCFA Type Service Code
1 68 68 CHAR
Code indicating the type of service, as defined
in the CMS Medicare Carrier Manual, for this
line item on the non-institutional claim.
DB2 ALIAS : HCFA_TYPE_SRVC_CD
SAS ALIAS : TYPSRVCB
STANDARD ALIAS : LINE_HCFA_TYPE_SRVC_CD
TITLE ALIAS : HCFA_TYPE_SRVC
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_HCFA_TYPE_SRVC_CD.
SOURCE : CWF
EDIT RULES :
The only type of service codes applicable to DMERC
claims are: 1, 9, A, E, G, H, J, K, L, M, P,
R, and S.
CODE TABLE : CMS_TYPE_SRVC_TB
130. Carrier Line Type Service Code
2 69 70 CHAR
Carrier's type of service code (usually
different from HCFA's) used for pricing the
service reported on the line item on the
carrier claim (non-DMERC).
DB2 ALIAS : LINE_TYPE_SRVC_CD
SAS ALIAS : PTYPESRV
STANDARD ALIAS : CARR_LINE_TYPE_SRVC_CD
TITLE ALIAS : CARR_TYPE_SRVC
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CWFB_CARR_TYPE_SRVC_CD.
SOURCE : CWF
131. Line Place of Service Code
2 71 72 CHAR
The code indicating the place of service, as
defined in the Medicare Carrier Manual, for
this line item on the noninstitutional claim.
COMMON ALIAS : POS
DB2 ALIAS : LINE_PLC_SRVC_CD
SAS ALIAS : PLCSRVC
STANDARD ALIAS : LINE_PLC_SRVC_CD
TITLE ALIAS : PLC_SRVC
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CWFB_PLC_SRVC_CD.
SOURCE : CWF
132. Carrier Line Pricing Locality Code
2 73 74 CHAR
Code denoting the carrier-specific locality
used for pricing the service for this line
item on the carrier claim (non-DMERC).
DB2 ALIAS : PRCNG_LCLTY_CD
SAS ALIAS : LCLTY_CD
STANDARD ALIAS : CARR_LINE_PRCNG_LCLTY_CD
TITLE ALIAS : PRICING_LOCALITY
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
CWFB_CARR_PRCNG_LCLTY_CD.
SOURCE : CWF
EDIT RULES :
CARRIER INFORMATION FILE
133. Line First Expense Date
8 75 82 NUM
Beginning date (1st expense) for this line item
service on the noninstitutional
claim.
DB2 ALIAS : LINE_1ST_EXPNS_DT
SAS ALIAS : EXPNSDT1
STANDARD ALIAS : LINE_1ST_EXPNS_DT
TITLE ALIAS : 1ST_EXPNS_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CWFB_1ST_EXPNS_DT.
SOURCE : CWF
EDIT RULES :
YYYYMMDD
134. Line Last Expense Date
8 83 90 NUM
The ending date (last expense) for the line
item service on the noninstitutional claim.
COBOL ALIAS : LST_EXP_DT
DB2 ALIAS : LINE_LAST_EXPNS_DT
SAS ALIAS : EXPNSDT2
STANDARD ALIAS : LINE_LAST_EXPNS_DT
TITLE ALIAS : LAST_EXPNS_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CWFB_LAST_EXPNS_DT.
SOURCE : CWF
EDIT RULES :
YYYYMMDD
135. Line HCPCS Code
5 91 95 CHAR
The Health Care Common Procedure Coding
System (HCPCS) is a collection of codes that
represent procedures, supplies, products and
services which may be provided to Medicare
beneficiaries and to individuals enrolled in
private health insurance programs. The codes
are divided into three levels, or groups as
described below:
DB2 ALIAS : LINE_HCPCS_CD
SAS ALIAS : HCPCS_CD
STANDARD ALIAS : LINE_HCPCS_CD
TITLE ALIAS : HCPCS_CD
LENGTH : 5
COMMENTS :
Prior to Version H this line item field was
named: HCPCS_CD. With Version H, a prefix
was added to denote the location of this field
on each claim type (institutional: REV_CNTR and
noninstitutional: LINE).
Level I
Codes and descriptors copyrighted by the American
Medical Association's Current Procedural
Terminology, Fourth Edition (CPT-4). These are
5 position numeric codes representing physician
and nonphysician services.
**** Note: ****
CPT-4 codes including both long and short
descriptions shall be used in accordance with the
CMS/AMA agreement. Any other use violates the
AMA copyright.
Level II
Includes codes and descriptors copyrighted by
the American Dental Association's Current Dental
Terminology, Fifth Edition (CDT-5). These are
5 position alpha-numeric codes comprising
the D series. All other level II codes and
descriptors are approved and maintained jointly
by the alpha-numeric editorial panel (consisting
of CMS, the Health Insurance Association of
America, and the Blue Cross and Blue Shield
Association). These are 5 position alpha-
numeric codes representing primarily items and
nonphysician services that are not
represented in the level I codes.
Level III
Codes and descriptors developed by Medicare
carriers for use at the local (carrier) level.
These are 5 position alpha-numeric codes in the
W, X, Y or Z series representing physician
and nonphysician services that are not
represented in the level I or level II codes.
136. Line HCPCS Initial Modifier Code
2 96 97 CHAR
A first modifier to the HCPCS procedure code
to enable a more specific procedure
identification for the line item service
on the noninstitutional claim.
DB2 ALIAS : UNDEFINED
SAS ALIAS : MDFR_CD1
STANDARD ALIAS : LINE_HCPCS_INITL_MDFR_CD
TITLE ALIAS : INITIAL_MODIFIER
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
HCPCS_INITL_MDFR_CD. With Version H, a prefix
was added to denote the location of this field
on each claim type (institutional: REV_CNTR and
noninstitutional: LINE).
SOURCE : CWF
EDIT RULES :
CARRIER INFORMATION FILE
137. Line HCPCS Second Modifier Code
2 98 99 CHAR
A second modifier to the HCPCS procedure code to
make it more specific than the first modifier
code to identify the line item procedures for
this claim.
DB2 ALIAS : UNDEFINED
SAS ALIAS : MDFR_CD2
STANDARD ALIAS : LINE_HCPCS_2ND_MDFR_CD
TITLE ALIAS : SECOND_MODIFIER
LENGTH : 2
COMMENTS :
Prior to Version H this field was named:
HCPCS_2ND_MDFR_CD. With Version H, a prefix
was added to denote the location of this field
on each claim type (institutional: REV_CNTR and
noninstitutional: LINE).
SOURCE : CWF
EDIT RULES :
CARRIER INFORMATION FILE
138. Line NCH BETOS Code
3 100 102 CHAR
Effective with Version H, the Berenson-Eggers
type of service (BETOS) for the procedure code
based on generally agreed upon clinically
meaningful groupings of procedures and services.
This field is included as a line item on the
noninstitutional claim.
NOTE: During the Version H conversion this field
was populated with data throughout history (back
to service year 1991).
DB2 ALIAS : LINE_NCH_BETOS_CD
SAS ALIAS : BETOS
STANDARD ALIAS : LINE_NCH_BETOS_CD
TITLE ALIAS : BETOS
LENGTH : 3
DERIVATIONS :
DERIVED FROM:
LINE_HCPCS_CD
LINE_HCPCS_INITL_MDFR_CD
LINE_HCPCS_2ND_MDFR_CD
HCPCS MASTER FILE
DERIVATION RULES:
Match the HCPCS on the claim to the HCPCS on
the HCPCS Master File to obtain the BETOS code.
SOURCE : NCH
CODE TABLE : BETOS_TB
139. Line IDE Number
7 103 109 CHAR
Effective with Version H, the exemption number
assigned by the Food and Drug Administration (FDA)
to an investigational device after a manufacturer
has been approved by FDA to conduct a clinical
trial on that device. HCFA established a new
policy of covering certain IDE's which was
implemented in claims processing on 10/1/96
(which is NCH weekly process 10/4/96) for service
dates beginning 10/1/95.
NOTE: Prior to Version H a dummy line item was
created in the last occurrence of line item group
to store IDE. The IDE number was housed in two
fields: HCPCS code and HCPCS initial modifier;
the second modifier contained the value 'ID'.
There will be only one distinct IDE number
reported on the non-institutional claim. During
the Version H conversion, the IDE was moved from
the dummy line item to its own dedicated field
for each line item (i.e., the IDE was repeated
on all line items on the claim.)
DB2 ALIAS : LINE_IDE_NUM
SAS ALIAS : LINE_IDE
STANDARD ALIAS : LINE_IDE_NUM
TITLE ALIAS : IDE_NUMBER
LENGTH : 7
SOURCE : CWF
140. Line National Drug Code
11 110 120 CHAR
Effective 1/1/94 on the DMERC claim, the National
Drug Code identifying the oral anti-cancer drugs.
Effective with Version H, this line item field was
added as a placeholder on the carrier claim.
DB2 ALIAS : LINE_NATL_DRUG_CD
SAS ALIAS : NDC_CD
STANDARD ALIAS : LINE_NATL_DRUG_CD
TITLE ALIAS : NDC_CD
LENGTH : 11
SOURCE : CWF
141. Line NCH Payment Amount
6 121 126 PACK
Amount of payment made from the trust funds (after
deductible and coinsurance amounts have been
paid) for the line item service on the non-
institutional claim.
COMMON ALIAS : REIMBURSEMENT
DB2 ALIAS : LINE_NCH_PMT_AMT
SAS ALIAS : LINEPMT
STANDARD ALIAS : LINE_NCH_PMT_AMT
TITLE ALIAS : REIMBURSEMENT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this line item field was named:
CLM_PMT_AMT and the size of this field was
S9(7)V99.
SOURCE : NCH
EDIT RULES :
$$$$$$$$$CC
142. Line Beneficiary Payment Amount
6 127 132 PACK
Effective with Version H, the payment (reim-
bursement) made to the beneficiary related
to the line item service on the noninstitu-
tional claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : LINE_BENE_PMT_AMT
SAS ALIAS : LBENPMT
STANDARD ALIAS : LINE_BENE_PMT_AMT
TITLE ALIAS : BENE_PMT_AMT
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
143. Line Provider Payment Amount
6 133 138 PACK
Effective with Version H, the payment
made to the provider for the line item
service on the noninstitutional claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : LINE_PRVDR_PMT_AMT
SAS ALIAS : LPRVPMT
STANDARD ALIAS : LINE_PRVDR_PMT_AMT
TITLE ALIAS : PRVDR_PMT_AMT
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
144. Line Beneficiary Part B Deductible Amount
6 139 144 PACK
The amount of money for which the
carrier has determined that the beneficiary
is liable for the Part B cash deductible
for the line item service on the noninstitutional
claim.
DB2 ALIAS : LINE_DDCTBL_AMT
SAS ALIAS : LDEDAMT
STANDARD ALIAS : LINE_BENE_PTB_DDCTBL_AMT
TITLE ALIAS : PTB_DED_AMT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
BENE_PTB_DDCTBL_LBLTY_AMT and the size of the
field was S9(3)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
145. Line Beneficiary Primary Payer Code
1 145 145 CHAR
The code specifying a federal non-Medicare program
or other source that has primary responsibility
for the payment of the Medicare beneficiary's
medical bills relating to the line item service
on the noninstitutional claim.
DB2 ALIAS : LINE_PRMRY_PYR_CD
SAS ALIAS : LPRPAYCD
STANDARD ALIAS : LINE_BENE_PRMRY_PYR_CD
TITLE ALIAS : PRIMARY_PAYER_CD
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
BENE_PRMRY_PYR_CD.
SOURCE : CWF,VA,DOL,SSA
CODE TABLE : BENE_PRMRY_PYR_TB
146. Line Beneficiary Primary Payer Paid Amount
6 146 151 PACK
The amount of a payment made on behalf of a
Medicare beneficiary by a primary payer other
than Medicare, that the provider is applying
to covered Medicare charges for to the line
ITEM SERVICE ON THE NONINSTITUTIONAL.
DB2 ALIAS : LINE_PRMRY_PYR_PD
SAS ALIAS : LPRPDAMT
STANDARD ALIAS : LINE_BENE_PRMRY_PYR_PD_AMT
TITLE ALIAS : PRMRY_PYR_PD
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
BENE_PRMRY_PYR_PMY_AMT and the field size
was S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
147. Line Coinsurance Amount
6 152 157 PACK
Effective with Version H, the beneficiary
coinsurance liability amount for this line
item service on the noninstitutional claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : LINE_COINSRNC_AMT
SAS ALIAS : COINAMT
STANDARD ALIAS : LINE_COINSRNC_AMT
TITLE ALIAS : COINSRNC_AMT
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
148. Carrier Line Psychiatric, Occupational Therapy, Physical Therapy Limit Amount
6 158 163 PACK
For type of service psychiatric, occupational
therapy or physical therapy, the amount of
allowed charges applied toward the limit cap
for this line item service on the noninstitutional
claim.
DB2 ALIAS : PSYCH_OT_PT_LMT
SAS ALIAS : LLMTAMT
STANDARD ALIAS : CARR_LINE_PSYCH_OT_PT_LMT_AMT
TITLE ALIAS : PSYCH_OT_PT_LIMIT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_PSYCH_OT_PT_LMT_AMT and the field size
was S9(5)V99.
SOURCE : CWF
149. Line Interest Amount
6 164 169 PACK
Amount of interest to be paid for this line
item service on the noninstitutional claim.
**NOTE: This is not included in the line item
NCH payment (reimbursement) amount.
DB2 ALIAS : LINE_INTRST_AMT
SAS ALIAS : LINT_AMT
STANDARD ALIAS : LINE_INTRST_AMT
TITLE ALIAS : INTRST_AMT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_INTRST_AMT and the field size was
S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
150. Line Primary Payer Allowed Charge Amount
6 170 175 PACK
Effective with Version H, the primary payer
allowed charge amount for the line item
service on the noninstitutional claim.
NOTE: Beginning with NCH weekly process date
10/3/97 this field was populated with data.
Claims processed prior to 10/3/97 will contain
zeroes in this field.
DB2 ALIAS : PRMRY_PYR_ALOW_AMT
SAS ALIAS : PRPYALOW
STANDARD ALIAS : LINE_PRMRY_PYR_ALOW_CHRG_AMT
TITLE ALIAS : PRMRY_PYR_ALOW_CHRG
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
151. Line 10% Penalty Reduction Amount
6 176 181 PACK
Effective with Version H, the 10% payment
reduction amount (applicable to a late
filing claim) for the line item service.
on the noninstitutional claim.
DB2 ALIAS : TENPCT_PNLTY_AMT
SAS ALIAS : PNLTYAMT
STANDARD ALIAS : LINE_10PCT_PNLTY_RDCTN_AMT
TITLE ALIAS : TENPCT_PNLTY
LENGTH : 9.2 SIGNED : Y
SOURCE : CWF
152. Carrier Line Blood Deductible Pints Quantity
2 182 183 PACK
The blood pints quantity (deductible) for the
line item on the carrier claim (non-DMERC).
DB2 ALIAS : LINE_BLOOD_DDCTBL
SAS ALIAS : LBLD_DED
STANDARD ALIAS : CARR_LINE_BLOOD_DDCTBL_QTY
TITLE ALIAS : BLOOD_DDCTBL
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_LINE_BLOOD_DDCTBL_QTY.
SOURCE : CWF
EDIT RULES :
NUMERIC
153. Line Submitted Charge Amount
6 184 189 PACK
The amount of submitted charges for the line
item service on the noninstitutional claim.
DB2 ALIAS : LINE_SBMT_CHRG_AMT
SAS ALIAS : LSBMTCHG
STANDARD ALIAS : LINE_SBMT_CHRG_AMT
TITLE ALIAS : SBMT_CHRG
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_SBMT_CHRG_AMT and the field size was
S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
154. Line Allowed Charge Amount
6 190 195 PACK
The amount of allowed charges for the line item
service on the noninstitutional claim. This
charge is used to compute pay to providers or
reimbursement to beneficiaries. **NOTE: The
Note1: The amount includes beneficiary-paid
amounts (i.e., deductible and coinsurance).
Note2: The allowed charge is determined by the
lower of three charges: prevailing, customary or
actual.
DB2 ALIAS : LINE_ALOW_CHRG_AMT
SAS ALIAS : LALOWCHG
STANDARD ALIAS : LINE_ALOW_CHRG_AMT
TITLE ALIAS : ALOW_CHRG
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_ALOW_CHRG_AMT and the field size was
S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$CC
155. Carrier Line Clinical Lab Number
10 196 205 CHAR
The identification number assigned to the
clinical laboratory providing services for
the line item on the carrier claim (non-DMERC).
DB2 ALIAS : CLNCL_LAB_NUM
SAS ALIAS : LAB_NUM
STANDARD ALIAS : CARR_LINE_CLNCL_LAB_NUM
TITLE ALIAS : LAB_NUM
LENGTH : 10
COMMENTS :
Prior to Version H this field was named:
CWFB_CLNCL_LAB_NUM.
SOURCE : CWF
156. Carrier Line Clinical Lab Charge Amount
6 206 211 PACK
Fee schedule charge amount applied for the line
item clinical laboratory service on the carrier
claim (non-DMERC).
DB2 ALIAS : CLNCL_LAB_CHRG_AMT
SAS ALIAS : LAB_AMT
STANDARD ALIAS : CARR_LINE_CLNCL_LAB_CHRG_AMT
TITLE ALIAS : LAB_CHRG
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_CLNCL_LAB_CHRG_AMT and the field size was
S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$C
157. Line Processing Indicator Code
1 212 212 CHAR
The code indicating the reason a line item
on the noninstitutional claim was allowed
or denied.
NOTE2: Effective 4/1/02, this field was
expanded to two bytes to accommodate new values.
The NCH Nearline file did not expand the current
1-byte field but instituted a crosswalk of the
2-byte field to the 1-byte character value.
See table of code for the crosswalk.
DB2 ALIAS : LINE_PRCSG_IND_CD
SAS ALIAS : PRCNGIND
STANDARD ALIAS : LINE_PRCSG_IND_CD
TITLE ALIAS : PRCSG_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_PRCSG_IND_CD.
SOURCE : CWF
CODE TABLE : LINE_PRCSG_IND_TB
158. Line Payment 80%/100% Code
1 213 213 CHAR
The code indicating that the amount shown in the
payment field on the noninstitutional line item
represents either 80% or 100% of the allowed
charges less any deductible, or 100% limitation
of liability only.
COMMON ALIAS : REIMBURSEMENT_IND
DB2 ALIAS : LINE_PMT_80_100_CD
SAS ALIAS : PMTINDSW
STANDARD ALIAS : LINE_PMT_80_100_CD
TITLE ALIAS : REINBURSEMENT_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_PMT_80_100_CD.
SOURCE : CWF
159. Line Service Deductible Indicator Switch
1 214 214 CHAR
Switch indicating whether or not the line item
service on the noninstitutional claim is subject
to a deductible.
DB2 ALIAS : SRVC_DDCTBL_SW
SAS ALIAS : DED_SW
STANDARD ALIAS : LINE_SRVC_DDCTBL_IND_SW
TITLE ALIAS : SRVC_DED_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_SRVC_DDCTBL_IND_SW.
SOURCE : CWF
CODE TABLE : LINE_SRVC_DDCTBL_IND_TB
160. Line Payment Indicator Code
1 215 215 CHAR
Code that indicates the payment screen used to
determine the allowed charge for the line item
service on the noninstitutional claim.
DB2 ALIAS : LINE_PMT_IND_CD
SAS ALIAS : PMTINDCD
STANDARD ALIAS : LINE_PMT_IND_CD
TITLE ALIAS : PMT_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_PMT_IND_CD.
SOURCE : CWF
161. Carrier Line Miles/Time/Units/Services Count
2 216 217 PACK
The count of the total units associated with
services needing unit reporting such as
transportation, miles, anesthesia time units,
number of services, volume of oxygen or blood
units. This is a line item field on the carrier
claim (non-DMERC) and is used for both allowed
and denied services.
NOTE: For anesthesia (MTUS Indicator = 2) this
field should be reported in time unit intervals,
i.e. 15 minute interals or fraction thereof. It
appears that some carriers are reporting minutes
instead of time units.
DB2 ALIAS : LINE_MTUS_CNT
SAS ALIAS : MTUS_CNT
STANDARD ALIAS : CARR_LINE_MTUS_CNT
TITLE ALIAS : MTUS_CNT
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_MTUS_CNT.
SOURCE : CWF
EDIT RULES :
For CARR_LINE_MTUS_IND_CD equal to 2 (anesthesia
time units) there is one implied decimal point.
162. Carrier Line Miles/Time/Units/Services Indicator Code
1 218 218 CHAR
Code indicating the units associated with
services needing unit reporting on the line
item for the carrier claim (non-DMERC).
DB2 ALIAS : LINE_MTUS_IND_CD
SAS ALIAS : MTUS_IND
STANDARD ALIAS : CARR_LINE_MTUS_IND_CD
TITLE ALIAS : MTUS_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_MTUS_IND_CD.
SOURCE : CWF
CODE TABLE : CARR_LINE_MTUS_IND_TB
163. Line Diagnosis Code
5 219 223 CHAR
The ICD-9-CM code indicating the diagnosis
supporting this line item procedure/service
on the noninstitutional claim.
DB2 ALIAS : LINE_DGNS_CD
SAS ALIAS : LINEDGNS
STANDARD ALIAS : LINE_DGNS_CD
TITLE ALIAS : DGNS_CD
LENGTH : 5
COMMENTS :
Prior to Version H this field was named:
CWFB_LINE_DGNS_CD.
SOURCE : CWF
EDIT RULES :
ICD-9-CM
164. FILLER CHAR
1 224 224
DB2 ALIAS : FILLER
LENGTH : 1
165. Carrier Line Anesthesia Base Unit Count
2 225 226 PACK
The base number of units assigned to the line
item anesthesia procedure on the carrier claim
(non-DMERC).
DB2 ALIAS : ANSTHSA_UNIT_CNT
SAS ALIAS : ANSTHUNT
STANDARD ALIAS : CARR_LINE_ANSTHSA_UNIT_CNT
TITLE ALIAS : ANSTHSA_UNITS
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_ANSTHSA_BASE_UNIT_CNT.
SOURCE : CWF
166. Carrier Line CLIA Alert Indicator Code
1 227 227 CHAR
Effective with Version G, the alert code (resulting
from CLIA editing) added by CWF as a line item
on the carrier claim (non-DMERC).
DB2 ALIAS : CLIA_ALERT_IND_CD
SAS ALIAS : CLIAALRT
STANDARD ALIAS : CARR_LINE_CLIA_ALERT_IND_CD
TITLE ALIAS : CLIA_ALERT
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_CLIA_ALERT_IND_CD.
SOURCE : CWF
CODE TABLE : CARR_LINE_CLIA_ALERT_IND_TB
167. Line Additional Claim Documentation Indicator Code
1 228 228 CHAR
Effective 5/92, the code indicating additional
claim documentation was submitted for this line
item service on the noninstitutional claim.
COMMON ALIAS : DOCUMENT_IND
DB2 ALIAS : ADDTNL_DCMTN_CD
SAS ALIAS : DCMTN_CD
STANDARD ALIAS : LINE_ADDTNL_CLM_DCMTN_IND_CD
TITLE ALIAS : ADDTNL_DCMTN_IND
LENGTH : 1
COMMENTS :
Prior to Version H this field was named:
CWFB_ADDTNL_CLM_DCMTN_IND_CD.
SOURCE : CWF
EDIT RULES :
In any case where more than one value is
applicable, highest number is shown.
CODE TABLE : LINE_ADDTNL_CLM_DCMTN_IND_TB
168. Carrier Line DME Coverage Period Start Date
8 229 236 NUM
Effective 5/92 through 6/94, as line item on the
carrier claim (non-DMERC), the date durable medical
equipment (DME) coverage period started per certi-
ficate of medical necessity, prescription, other
documentation or carrier determination. This field
is applicable to line items involving DME,
prosthetic, orthotic and supply items, immuno-
suppressive drugs, pen, ESRD and oxygen items
referred to as DMEPOS).
DB2 ALIAS : DME_CVRG_STRT_DT
SAS ALIAS : DMEST_DT
STANDARD ALIAS : CARR_LINE_DME_CVRG_PRD_STRT_DT
TITLE ALIAS : DME_CVRG_START_DT
LENGTH : 8 SIGNED : N
COMMENTS :
Prior to Version H this field was named:
CWFB_DME_CVRG_PRD_STRT_DT.
SOURCE : CWF
LIMITATIONS :
When the revised DME processing was implemented
(phased in between 10/93-6/94), this field was not
included on the new DMERC claim; it is being
reported on the certificate of medical necessity
(CMN) transaction. HCFA does not receivee CMN
transaction from CWF.
EDIT RULES :
YYYYMMDD
169. Line DME Purchase Price Amount
6 237 242 PACK
Effective 5/92, the amount representing the
lower of fee schedule for purchase of new or
used DME, or actual charge. In case of rental
DME, this amount represents the purchase cap;
rental payments can only be made until the
cap is met. This line item field is applicable
to non-institutional claims involving DME,
prosthetic, orthotic and supply items,
immunosuppressive drugs, pen, ESRD and oxygen
items referred to as DMEPOS.
DB2 ALIAS : DME_PURC_PRICE_AMT
SAS ALIAS : DME_PURC
STANDARD ALIAS : LINE_DME_PURC_PRICE_AMT
TITLE ALIAS : DME_PURC_PRICE
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_DME_PURC_PRICE_AMT and the field size
was S9(5)V99.
SOURCE : CWF
EDIT RULES :
$$$$$$$$$CC
170. Carrier Line DME Medical Necessity Month Count
2 243 244 PACK
Effective 5/92 through 6/94, as line item on the
carrier claim (non-DMERC), the count determined by
the carrier showing the length of need (medical
necessity for DME in months from the start date
through the determined period of need.
This field is applicable to line items involving
DME, prosthetic, orthotic and supply items, immuno-
suppressive drugs, pen, ESRD and oxygen items
referred to as DMEPOS).
Exception: If the DME is determined to be
medically necessary for the life
of the beneficiary, 99 is placed
in this field, rather than a month
count.
DB2 ALIAS : DME_NCSTY_MO_CNT
SAS ALIAS : NCSTY_MO
STANDARD ALIAS : CARR_LINE_DME_NCSTY_MO_CNT
TITLE ALIAS : DME_NCSTY_MONTHS
LENGTH : 3 SIGNED : Y
COMMENTS :
Prior to Version H this field was named:
CWFB_DME_MDCL_NCSTY_MO_CNT.
SOURCE : CWF
LIMITATIONS :
When the revised DME processing was implemented
(phased in between 10/93-6/94), this field was not
included on the new DMERC claim; it is being
reported on the certificate of medical necessity
(CMN) transaction. HCFA does not receive CMN
transaction from CWF.
171. Line Consolidated Billing Indicator Code
1 245 245 CHAR
Effective 1/1/2004 with implementation of NCH/NMUD
CR#1, this code is reflected on carrier & DMERC claims
to identify those line item services (i.e. therapy
and nonroutine supply services) that are subject
to SNF and Home Health consolidated billing. If the
line item service was paid by a carrier prior
to the submission of the SNF or home health claim
an adjustment for the carrier or DMERC claim will
be submitted identifying those services that are
subject to consolidated billing.
NOTE1: Prior to 10/2005 (implementation of NCH/NMUD
CR#2), this data was stored in position 245 (FILLER)
of the line item trailer.
Effective July 2005, this data will no longer be coming
into the NCH.
DB2 ALIAS : CNSLDTD_BLG_CD
SAS ALIAS : LCNSLDTD
STANDARD ALIAS : LINE_CNSLDTD_BLG_CD
LENGTH : 1
CODE TABLE : LINE_CNSLDTD_BLG_TB
172. Line Duplicate Claim Check Indicator Code
1 246 246 CHAR
Effective 1/1/2004 with the implementation of NCH/NMUD
CR#1, the code used to identify an item or service that
appeared to be a duplicate but has been reviewed by a
carrier and appropriately approved for payment.
NOTE1: Prior to 10/2005 (implementation of NCH/NMUD
CR#2), this data was stored in position 246 (FILLER)
on the line item trailer.
DB2 ALIAS : DUP_CLM_CHK_IND_CD
SAS ALIAS : DUP_CHK
STANDARD ALIAS : LINE_DUP_CLM_CHK_IND_CD
LENGTH : 1
SOURCE : CWF
CODE TABLE : LINE_DUP_CLM_CHK_IND_TB
173. Carrier Line Point of Pickup Zip Code
5 247 251 CHAR
Effective 1/1/2004 with the implementation of NCH/NMUD
CR#1, the code identifying the point of pickup
zip code on carrier claims. The point of pickup
zip code is used for pricing ambulance services.
NOTE: Prior to 10/2005 (implementation of NCH/NMUD
CR#2), this data was stored in positions 247-251 on
the carrier line item trailer.
DB2 ALIAS : PNT_PCKP_ZIP_CD
SAS ALIAS : PNT_PCKP
STANDARD ALIAS : CARR_LINE_PNT_PCKP_ZIP_CD
LENGTH : 5
SOURCE : CWF
174. Carrier Line HPSA/Scarcity Indicator Code
1 252 252 CHAR
Effective 10/3/2005 with the implementation of NCH/
NMUD CR#2, the code used to track health professional
shortage area (HPSA) and physician scarcity bonus
payments on carrier claims.
NOTE: Prior to 10/3/2005, claims contained a
modifier code to indicate the bonus payment. A
'QU' represented a HPSA bonus payment and an 'AR'
represented a scarcity bonus payment. As of 1/1/2005,
the modifiers were no longer being reported by the
provider. NCH & NMUD were not ready to accept the
new field until 10/3/2005.
DB2 ALIAS : HPSA_SCRCTY_IND_CD
SAS ALIAS : HSCRCTY
STANDARD ALIAS : CARR_LINE_HPSA_SCRCTY_IND_CD
LENGTH : 1
SOURCE : CWF
CODE TABLE : CARR_LINE_HPSA_SCRCTY_IND_TB
175. Carrier Line RX Number
30 253 282 CHAR
The number used to identify the prescrip-
tion order number for drugs and biologicals
purchased through the competitive acquisition
program (CAP).
NOTE1: MMA required the implementation of a
competative acquisition program (CAP) for
Part B drugs and biologicals not paid on a
cost or PPS basis. Physicians will be given
a choice between buying and billing these
drugs under the average sales price (ASP) or
obtaining these drugs from an approved CAP
vendor. The prescription number is needed
to identify which claims were submitted for
CAP drugs and their administration.
NOTE2: Eventhough this field was implemented
with NCH/NMUD CR#2, data will not be coming in
until 1/1/2006.
DB2 ALIAS : CARR_LINE_RX_NUM
SAS ALIAS : RX_NUM
STANDARD ALIAS : CARR_LINE_RX_NUM
LENGTH : 30
COMMENTS :
The prescription order number consist of:
--Vendor ID Number (positions 1 - 4)
--HCPCS Code (positions 5 - 9)
--Vendor Controlled Prescription Number
(positions 10 - 30)
SOURCE : CWF
176. Line Hematocrit/Hemoglobin Test Type Code
2 283 284 CHAR
Effective September 1, 2008 with the implementation
of CR#3, the code used to identify which reading is
reflected in the hematocrit/hemoglobin result number
field on the noninstitutional claim.
DB2 ALIAS : HCT_HGB_TYPE_CD
SAS ALIAS : HTYPECD
STANDARD ALIAS : LINE_HCT_HGB_TYPE_CD
LENGTH : 2
CODE TABLE : LINE_HCT_HGB_TYPE_TB
177. Line Hematocrit/Hemoglobin Result Number
3 285 287 CHAR
Effective September 1, 2008, with the implementation
of CR#3, the number used to identify the most recent
hematocrit or hemoglobin reading on the noninstitutional
claim.
NOTE: The hematocrit/hemoglobin test result field is a
redefined field. The field is being defined as X(3) and
redefined as numeric (99V9). A numeric test on the
alphanumeric field is needed. Whenever a user wants to
use the field they must test the alphanumeric field for
numerics and if it is numeric then the 99V9 definition
would be used. The older data will cause an abend if
trying to process numeric data with characters.
DB2 ALIAS : HCT_HGB_RSLT_NUM
SAS ALIAS : HRSLTNUM
STANDARD ALIAS : LINE_HCT_HGB_RSLT_NUM
LENGTH : 3
178. Line Hematocrit/Hemoglobin Result Number -- Redefined
3 285 287 NUM
Effective September 1, 2008, with the implementation
of CR#3, the number used to identify the most recent
hematocrit or hemoglobin reading on the noninstitutional
claim.
NOTE: The hematocrit/hemoglobin test result field is a
redefined field. The field is being defined as X(3) and
redefined as numeric (99V9). A numeric test on the
alphanumeric field is needed. Whenever a user wants to
use the field they must test the alphanumeric field for
numerics and if it is numeric then the 99V9 definition
would be used. The older data will cause an abend if
trying to process numeric data with characters.
DB2 ALIAS : HCT_HGB_RSLT_NUM
SAS ALIAS : HRLSTNUM
STANDARD ALIAS : LINE_HCT_HGB_RSLT_NUM_R
LENGTH : 2.1 SIGNED : N
REDEFINE : LINE_HCT_HGB_RSLT_NUM
179. FILLER CHAR
7 288 294
DB2 ALIAS : FILLER
LENGTH : 7
180. End of Record Code
3 1 3 CHAR
Effective with Version 'I', the code used
to identify the end of a record/segment or
the end of the claim.
DB2 ALIAS : END_REC_CD
SAS ALIAS : EOR
STANDARD ALIAS : END_REC_CD
TITLE ALIAS : END_OF_REC
LENGTH : 3
COMMENTS :
Prior to Version I this field was named:
END_REC_CNSTNT.
SOURCE : NCH
CODE TABLE : END_REC_TB