Partial episodic payment (PEP)

This payment occurs when a patient is transferred/discharged and readmitted to the same home health agency within a 60-day period. The original episode payment is adjusted according to the length of time the patient received care and the services provided. This is a proportional payment amount based on the number of days of service provided (i.e., the total number of days counted from and including the day of the first billable service to and including the day of the last billable service). The readmission episode starts a new 60-day episode for full payment.

Low-utilization payment adjustment (LUPA)

LUPA payments occur when there are fewer than five visits provided to the patient in the 60-day episode. LUPA payments are paid per visit and not according to the home health resource group (HHRG) calculation. Nonroutine supplies will not be reimbursed in addition to the visit payments, since total annual supply payments are factored into all payment rates. The LUPA add-on is an additional reimbursement for the first early episode when calculating as a LUPA episode.

Outlier payments  

Outlier payments occur when the patient has received a high utilization of services greater than the average home health services. The term “outlier” has been used by Medicare to address exceptional cases both in terms of cost and length of stay. The cost of caring for this patient is much higher than the episode’s designated reimbursement. The combined operating and capital costs of a case must exceed the fixed-loss outlier threshold to qualify for an outlier payment. The operating and capital costs are computed separately by multiplying the total covered charges by the operating and capital cost-to-charge ratios. Outliers are calculated if the total product that results from multiplying the number of the visits and the national standardized visit rate is greater than the sum of the case-mix specific payment amount plus the fixed-loss threshold amount. The fixed-loss threshold amount is a set percentage (known as the loss-sharing ratio) of the amount by which the product exceeds the sum that will be paid to the HHA as an outlier payment in addition to the episode. 

HHAs do not submit anything different on their claims to be eligible for outlier consideration. The outlier payment will be included on the remittance advice and will be identified separately on the claim in history using value code 17, with an associated dollar amount representing the outlier payment. Medicare reimbursement has an annual 10% cap on outlier payments per home health agency. Outlier payments cannot exceed 10% of the home health agency’s total PPS revenue for the year 

The Prospective Payment System (PPS)

Medicare Part A and Medicare Part B reimburse home health agencies a lump sum, which is divided into two payments for a 60-day episode of care. The bundled services provided during the 60-day episode include all skilled nursing, therapy, and home health aide visits along with nonroutine supplies. Some outpatient therapy services may be covered under the PPS benefit as well. The total payment is based on the Outcome and Assessment Information Set (OASIS) assessment scoring with geographical location using core-based statistical area (CBSA) codes. Chapter 10 of the Medicare Claims Processing Manual provides details on how to process Medicare claims. 

Home health resources groups (HHRG)

The federal prospective payment system for home health began on October 1, 2000, established by the Balanced Budget Act of 1997. This system created a case mix severity index that is adjusted for the health condition, clinical characteristics, and care needs of the patient. There are 153 different HHRGs.

PPS payment types

 There are many different types of payment under the PPS. These include the following 

Request for anticipated payment (RAP)

A RAP is the first payment received. The home health agency may submit a request for the initial anticipated payment based on receiving verbal orders from the physician and delivering at least one service to the patient. The RAP pays 60% of the episode’s worth for the initial episode and 50% of the episode’s worth for all subsequent episodes. Use “0322—Type of Bill (TOB)” (form locator 4) for RAP submission only. RAPs may be paid zero percent if Medicare is the secondary payer or if the patient is enrolled in a Medicare Advantage program. 

Final claim payment

The remaining split percentage payment due for the episode will be made based on a claim submitted at the end of the 60-day period, or after the patient is discharged, whichever is earlier. The claim may not be submitted until after all services are provided for the episode and the HHA has a signed the plan of care on file at the agency. Use “0329—Type of Bill (TOB)” (from locator 4) for final claims.

Medicare will recoup the RAP and submit final claim payment in full to the agency. The related remittance advice will show the RAP payment was recouped in full and a 100% payment for the episode was made on the final claim. The final claim payment is based upon the HHRG conversion to Health Insurance Prospective Payment System (HIPPS) code calculation, which is defined in this chapter, and the claim detail. The claim detail includes all visits provided and nonroutine supplies. The reimbursement often changes from the RAP estimate due to the number of therapy visits provided being different than what was projected at the beginning of the episode.

Medicare Health Benefit

The Medicare Health Benefit covers the following individuals:

• Age 65 or older 

• Younger than 65 with a disability 

• With end-stage renal disease (any age)

The Medicare home health benefit pays for homecare services under Part A and B. Beneficiaries do not have to have both Part A and B to receive homecare services.

Medicare Advantage plans

Medicare also contracts with a private company to offer patients their Part A and Part B benefits. Medicare Advantage Plans include HMOs, PPOs, private fee-for-service plans, special needs plans, and Medicare medical savings account plans. Services are paid for by the private company and not under Original Medicare.

Medicare Part A

Medicare Part A helps cover hospital inpatient care, skilled nursing facilities, hospice care, and home health care. Beneficiaries must meet certain required conditions to qualify for these benefits. Individuals and their spouses who paid the Medicare tax while working do not pay a monthly premium for the Medicare Part A benefit. Most people meet the requirement for a premium-free Part A; however, if they don’t meet the requirements for a premium-free Part A, it is available for a monthly fee.

Medicare Part A covers eligible home health services such as intermittent skilled nursing care, physical therapy, speech-language pathology services, continued occupational services, social services, home health aide services, and medical supplies used in the home. 

Medicare doesn’t pay for the following:

 • 24-hour-a-day care at home 

 • Meals delivered to the home  

 • Homemaker services 

 • Personal care 

Medicare Part B

Most people pay a monthly premium for Medicare Part B. Medicare Part B helps cover doctors’ services, outpatient care, outpatient therapy services, and limited home health care. Medicare Part B helps pay for these covered services and supplies when they are deemed to be medically necessary.

Home Health Billing Overview

A biller has an important role in homecare: to ensure that the information submitted on claims is precise and appropriate. Medical billing translates all of the healthcare service provided to a patient into a billing claim. The billing department is responsible for ensuring that the homecare agency has received accurate reimbursement based on information submitted. The billing department is the last quality control check before submitting the claim to the insurance company.

Biller’s Role and Required Skills 

The financial health of an agency is dependent on the performance of the billing department. Billers must understand requirements for eligibility, the claims submission and payment process, and how to participate in the appeals process.

Many skills are needed to be a home health biller. Billers should know how to do the following: 

• Establish eligibility with the understanding of a variety of insurance rules 

• Verify patients’ insurance coverage 

• Reduce risk of late or nonpayment by following timely filing guidelines 

• Creating a clean claim (i.e., one that follows rules and is accurate) for submission 

• Develop procedures to reduce accounts receivable (AR) days as much as possible 

• Follow a claim from initial payment to zero balance 

• Identify any appeals/denials and unpaid claims on remittance advice

• Understand requirements for refunds/paybacks 

• Handle collections on unpaid accounts 

• Use data and reports as performance indicators for potential areas of improvement 

• Answer patients’ billing questions 

• Manage the agency’s accounts receivable reports

A certified home health agency is authorized by the Centers for Medicare & Medicaid Services to accept Medicare and Medicaid reimbursement. Certified home health agencies must follow the Conditions of Participation 42 CFR 484 requirements.

Certified home health agencies provide skilled and intermittent services to individuals in their home environment. Home health allows people to stay in the comfort of their own home while receiving active treatment or routine care during the healing and recovery phase of their illness or injury. 

Certified home health agencies offer many services, including the following:

• Skilled nursing 

• Physical therapy 

• Occupational therapy

• Speech language pathology 

• Social worker services 

• Home health aide services 

Home health providers negotiate contracts with private health insurances. The contract will have a list of the reimbursement rates along with the specific billing codes required for the claims. The federal government determines the reimbursement rate for Medicare and Medicaid. Medicare releases the reimbursement rates each year. These rates are found in the annual Prospective Payment System (PPS) home health final rule. Medicaid lists the rates on the Medicaid website. Medicaid does not change the reimbursement rates every year

Understanding the federal regulations and billing requirements of each insurance plan is essential to home health agencies receiving accurate reimbursement for the services provided. As billing requirements change so often, it is challenging for agencies to remain financially stable. Home health agencies must continuously review billing best practices to be able to provide the best care to beneficiaries.

Home health providers are assigned to Medicare Administrative Contractor (MAC) jurisdictions. Each MAC offers providers ways to stay informed regarding requirement updates, manuals, and provider support. MACs are sometimes referred to as Fiscal Intermediaries (FI). 

Each MAC will have a listserv registration on the home page of their provider site. On the registration page, select the type of updates you would like to receive. General electronic data interchange (EDI) and education updates offer important information to the biller. Once registered, updates will auto-populate and be sent to your email address as the information is posted to the MAC site. 

Each MAC also offers customer service. Billers should contact their fiscal intermediary (FI) customer service department for claim status issues or EDI department for electronic claims and report issues.  

Claim Related Condition Code

Variable Name : RLTCND{x} where { x } ranges from 1 to 3

Label :Claim Related Condition Code

The code that indicates a condition relating to an institutional claim that may affect payer processing. DB2 ALIAS: CLM_RLT_COND_CD SAS ALIAS: RLT_COND STANDARD ALIAS: CLM_RLT_COND_CD SYSTEM ALIAS: LTCOND TITLE ALIAS: RELATED_CONDITION_CD CODES: 01 THRU 16 = Insurance related 17 THRU 30 = Special condition 31 THRU 35 = Student status codes which are required when a patient is a dependent child over 18 years old 36 THRU 45 = Accommodation 46 THRU 54 = CHAMPUS information 55 THRU 59 = Skilled nursing facility 60 THRU 70 = Prospective payment 71 THRU 99 = Renal dialysis setting A0 THRU B9 = Special program codes C0 THRU C9 = PRO approval services D0 THRU W0 = Change conditions CODES: REFER TO: CLM_RLT_COND_TB IN THE CODES APPENDIX SOURCE: CWF 

Variable Name : OCRCND{x} where { x } ranges from 1 to 30

Label : NCH Occurrence Trailer Indicator Code

Effective with Version H, the code indicating the presence of a occurrence code trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS: OCRNC_TRLR_IND_CD SAS ALIAS: OCRNCIND STANDARD ALIAS: NCH_OCRNC_TRLR_IND_CD CODES: O = Occurrence code trailer present SOURCE: NCH 

Variable Name : OCRCND{x} where { x } ranges from 1 to 30

Label : NCH Occurrence Trailer Indicator Code

Effective with Version H, the code indicating the presence of a occurrence code trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS: OCRNC_TRLR_IND_CD SAS ALIAS: OCRNCIND STANDARD ALIAS: NCH_OCRNC_TRLR_IND_CD CODES: O = Occurrence code trailer present SOURCE: NCH 

Variable Name : OCRCCD{x} where { x } ranges from 1 to 30

Label : Claim Related Occurrence Code

The code that identifies a significant event relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a specific date. DB2 ALIAS: CLM_RLT_OCRNC_CD SAS ALIAS: OCRNC_CD STANDARD ALIAS: CLM_RLT_OCRNC_CD SYSTEM ALIAS: LTOCRNC TITLE ALIAS: OCCURRENCE_CD CODES: 01 THRU 09 = Accident 10 THRU 19 = Medical condition 20 THRU 39 = Insurance related 40 THRU 69 = Service related A1-A3 = Miscellaneous CODES: REFER TO: CLM_RLT_OCRNC_TB IN THE CODES APPENDIX SOURCE: CWF

Variable Name : OCRCDT{x} where { x } ranges from 1 to 30

Label : Claim Related Occurrence Date

The date associated with a significant event related to an institutional claim that may affect payer processing. 8 DIGITS UNSIGNED DB2 ALIAS: CLM_RLT_OCRNC_DT SAS ALIAS: OCRNCDT STANDARD ALIAS: CLM_RLT_OCRNC_DT TITLE ALIAS: RLT_OCRNC_DT EDIT-RULES: YYYYMMDD SOURCE: CWF  

Claim Demonstration Information Text

Variable Name: DEMOTXT{x}  where { x } ranges from 1 to 5 

Label: Claim Demonstration Information Text

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 DERIVATION: 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 contain the CHOICES plan number, if both of the following 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 reflect '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

Variable Name: DGNSND{x} where { x } ranges from 1 to 10

Label: NCH Diagnosis Trailer Indicator Code

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 CODES: Y = Diagnosis code trailer present SOURCE: NCH 

Variable Name: DGNSCD{x} where { x } ranges from 1 to 10

Label: Claim Diagnosis Code

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 EDIT-RULES: ICD-9-CM COMMENT: Prior to Version H this field was named: CLM_OTHR_DGNS_CD. 

Variable Name: CNDND{x} where { x } ranges from 1 to 30

Label: NCH Condition Trailer Indicator Code

Effective with Version H, the code indicating the presence of a condition code trailer. NOTE: During the Version H conversion this field was populated throughout history (back to service year 1991). DB2 ALIAS: COND_TRLR_IND_CD SAS ALIAS: CONDIND STANDARD ALIAS: NCH_COND_TRLR_IND_CD CODES: C = Condition code trailer present SOURCE: NCH

NCH Demonstration Trailer Indicator Code

Variable Name: DEMOIND{x} where { x } ranges from 1 to 5

Label: NCH Demonstration Trailer Indicator Code 

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: DEMO_TRLR_IND_CD SAS ALIAS: DEMOIND STANDARD ALIAS: NCH_DEMO_TRLR_IND_CD TITLE ALIAS: DEMO_INDICATOR CODES: D = Demo trailer present SOURCE: NCH

Variable Name: DEMONUM{x} where { x } ranges from 1 to 5

Label: Claim Demonstration Identification Number

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 appropriate 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 traditionally noncovered physician services for medical consultation furnished via two-way, interactive 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 designated 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 presences of the MCO Plan Contract #. 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 crosswalked 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 ID '06' will end once Demo ID '07' is implemented. 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 = Participating Centers of Excellence (PCOE) Demo -- testing a negotiated all-inclusive pricing arrangement (bundled rates) for highcost acute care cardiovascular and orthopedic procedures performed in 60-100 premier facili - ties in the Chicago and San Francisco Regions or by current CABG providers. The inpatient claims will contain a DRG '104','105','106', '107','112','124','125','209',or '471'; the related physician/supplier claims will contain the claim payment denial reason code = 'D'. NOTE: The demo is on HOLD. The FI and carrier will add Demo ID '07' to claim. 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 implemented 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 effectiveness of LVRS and maximum medical therapy (including pulmonary rehab) for Medicare beneficiaries 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 SENSITIVE 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 improve outcomes of care and reduce Medicare expenditures under Part A and Part B. There will be at least 9 Coordinated Care Entities (CCEs). The selected entities will be assigned a provider number specifically for the demonstration services. NOTE: The demo is on HOLD. The FI and carrier will add Demo ID '37' to claim. 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 -- AVAILABLE IN NMUD.** 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 transmitting the claims to Trailblazers for processing. NOTE: Effective October, 2000 for carrier claims. DB2 ALIAS: CLM_DEMO_ID_NUM SAS ALIAS: DEMONUM STANDARD ALIAS: CLM_DEMO_ID_NUM TITLE ALIAS: DEMO_ID SOURCE: CWF 

MCO Period Effective Date

Variable Name:  MCFFDT{x} where { x } ranges from 1 to 2

Label: MCO Period Effective Date 

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. 8 DIGITS UNSIGNED DB2 ALIAS: MCO_PRD_EFCTV_DT SAS ALIAS: MCOEFFDT STANDARD ALIAS: MCO_PRD_EFCTV_DT TITLE ALIAS: MCO_PERIOD_EFF_DT EDIT-RULES: YYYYMMDD SOURCE: CWF

Variable Name: MCTRMDT{x} where { x } ranges from 1 to 2

Label: MCO Period Termination Date

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. 8 DIGITS UNSIGNED DB2 ALIAS: MCO_PRD_TRMNTN_DT SAS ALIAS: MCOTRMDT STANDARD ALIAS: MCO_PRD_TRMNTN_DT TITLE ALIAS: MCO_PERIOD_TERM_DT EDIT-RULES: YYYYMMDD SOURCE: CWF

Variable Name: MCPLND{x} where { x } ranges from 1 to 2

Label: MCO Health PLANID Number

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 COMMENT: Prior to Version I this field was named: MCO_PAYERID_NUM. SOURCE: CWF  

Variable Name: PLNDND{x} where { x } ranges from 1 to 3

Label:  NCH Health PlanID Trailer Indicator Code

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: PLANID_TRLR_CD SAS ALIAS: PLANIDIN STANDARD ALIAS: NCH_HLTH_PLANID_TRLR_IND_CD CODES: I = Health PlanID trailer present COMMENT: Prior to Version I this field was named: NCH_PAYERID_TRLR_IND_CD. SOURCE: NCH

Variable Name: PLNDCD{x} where { x } ranges from 1 to 3

Label:   Claim Health PlanID Code

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: CLM_PLANID_CD SAS ALIAS: PLANIDCD STANDARD ALIAS: CLM_HLTH_PLANID_CD TITLE ALIAS: PLANID_TYPE CODES: 1 = Medicare Secondary Payer 2 = Medicaid 3 = Medigap 4 = Supplemental Insurer 5 = Managed Care Organization COMMENT: Prior to Version I this field was named: CLM_PAYERID_CD. SOURCE: CWF 

Variable Name: PLANID{x} where { x } ranges from 1 to 3

Label:   Claim Health PlanID Number

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: CLM_PLANID_NUM

SAS ALIAS: PLANID STANDARD ALIAS: CLM_HLTH_PLANID_NUM TITLE ALIAS: PLANID COMMENT: Prior to Version I this field was named: CLM_PAYERID_NUM. SOURCE: CWF  

NCH Patch Code

Variable Name : PTCHCD{x} where { x } ranges from 1 to 30  

Label:  NCH Patch Code

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 CODES: REFER TO: NCH_PATCH_TB IN THE CODES APPENDIX SOURCE: NCH  

Variable Name : PTCHDT{x} where { x } ranges from 1 to 30

Label:  NCH Patch Applied Date

Effective with Version H, the date the NCH patch was applied to the claim. 8 DIGITS UNSIGNED DB2 ALIAS: NCH_PATCH_APPLY_DT SAS ALIAS: PATCHDT STANDARD ALIAS: NCH_PATCH_APPLY_DT TITLE ALIAS: NCH_PATCH_DT EDIT-RULES: YYYYMMDD SOURCE: NCH 

Variable Name : MCOIND{x} where { x } ranges from 1 to 2

Label:   NCH MCO Trailer Indicator Code

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 CODES: M = MCO trailer present SOURCE: NCH QA Process 

Variable Name : MCONUM{x} where { x } ranges from 1 to 2

Label:   MCO Contract Number

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 SOURCE: CWF

Variable Name : MCOOPTN{x} where { x } ranges from 1 to 2

Label:   MCO Option Code

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 CODES: *****For lock-in beneficiaries**** A = HCFA to process all provider bills B = MCO to process only in-plan C = MCO to process all Part A and Part B bills ***** For non-lock-in beneficiaries***** 1 = HCFA to process all provider bills 2 = MCO to process only in-plan Part A and Part B bills SOURCE: CWF  

Claim HHA Care Start Date

Variable Name :HHSTRTDT

Label :  Claim HHA Care Start Date

Effective with Version H, the date care started for the HHA services reported on the institutional claim with a from date greater than 3/31/98. The Balanced Budget Act (BBA) required that this field be present on all HHA claims. 

NOTE1: Beginning with NCH weekly process date 4/3/98, this field was populated with data. Claims processed prior to 4/3/98 will contain zeroes in this field. 

NOTE2: Effective with Version 'I', the start of care date will be moved from the 1st eight positions of the Claim Treatment Authorization Number. Prior to Version 'I' this date was moved from Occurrence Code 27 date field. 8 DIGITS UNSIGNED 

DB2 ALIAS: HHA_CARE_STRT_DT 

SAS ALIAS: HHSTRTDT 

STANDARD ALIAS: CLM_HHA_CARE_STRT_DT 

TITLE ALIAS: HHA_CARE_START_DT EDIT-RULES: YYYYMMDD 

SOURCE: CWF

Variable Name :   HHSTRTDT EDTND{x} where { x } ranges from 1 to 13

Label :  NCH Edit Trailer Indicator Code

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 CODES: 

E = Edit code trailer present SOURCE: NCH QA Process 

Variable Name :   EDITCD{x} where { x } ranges from 1 to 13

Label :  NCH Edit Code

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 CODES: REFER TO: NCH_EDIT_TB IN THE CODES APPENDIX SOURCE: NCH QA EDIT PROCESS

Variable Name :   PTCHND{x} where { x } ranges from 1 to 30

Label :  NCH Patch Trailer Indicator Code

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 CODES: P = Patch code trailer present SOURCE: NCH 

Claim HHA Total Visit Count

Variable Name :VISITCNT

Label :  Claim HHA Total Visit Count

Effective with Version H, the count of the number of HHA visits as derived by CWF. 

NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991) using the CWF derivation rule (units associated with revenue center codes 042X, 043X, 044X, 055X, 056X, 057X, 058X and 059X. Value '999' will be displayed if the sum of the revenue center unit count equals or exceeds '999'. 

NOTE2: Effective 7/1/99, all HHA claims received with service from dates 7/1/99 and after will be processed as if the units field contains the 15 minute interval count; and each visit revenue code line item will be counted as ONE visit. This field is calculated correctly; but those users who derive the count themselves they will have to revise their routine. 

NO LONGER IS THE COUNT DERIVED BY ADDING UP THE UNITS FIELDS ASSOCIATED WITH THE HHA VISIT REVENUE CODES. 3 DIGITS SIGNED DB2 

ALIAS: HHA_TOT_VISIT_CNT 

SAS ALIAS: VISITCNT 

STANDARD ALIAS: CLM_HHA_TOT_VISIT_CNT 

TITLE ALIAS: HHA_TOT_VISITS 

SOURCE: CWF 

Variable Name :QLFYFROM

Label :   NCH Qualified Stay From Date

Effective with Version H, the beginning date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes). For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than 'A'. 

NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991).

8 DIGITS UNSIGNED 

DB2 ALIAS: QLFY_STAY_FROM_DT 

SAS ALIAS: QLFYFROM 

STANDARD ALIAS: NCH_QLFY_STAY_FROM_DT 

TITLE ALIAS: QLFYG_STAY_FROM_DT EDIT-RULES: YYYYMMDD 

DERIVATION: DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_FROM_DT DERIVATION RULES: Based on the presence of occurrence code 70 move the related occurrence from date to NCH_QLFY_STAY_FROM_DT. 

SOURCE: NCH QA Process

Variable Name :QLFYTHRU

Label :  NCH Qualify Stay Through Date

Effective with Version H, the ending date of the beneficiary's qualifying stay (used for internal CWFMQA editing purposes.) For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization to benefits. For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if the source of admission is an 'A', or at least three days in a row if the source of admission is other than 'A'. 

NOTE: During the Version H, conversion this field was populated with data throughout history (back to service year 1991). 8 DIGITS UNSIGNED 
DB2 ALIAS: QLFY_STAY_THRU_DT 
SAS ALIAS: QLFYTHRU STANDARD ALIAS: NCH_QLFY_STAY_THRU_DT
TITLE ALIAS: QLFYG_STAY_THRU_DT EDIT-RULES: YYYYMMDD DERIVATION: DERIVED FROM: CLM_OCRNC_SPAN_CD CLM_OCRNC_SPAN_THRU_DT DERIVATION RULES: Based on the presence of occurrence code 70 move the related occurrence thru date to NCH_QLFY_STAY_THRU_DT.
 SOURCE: NCH QA Process  

Variable Name :DSCHRGDT

Label :  NCH Beneficiary Discharge Date

Effective with Version H, on an inpatient and HHA claim, the date the beneficiary was discharged from the facility or died (used for internal CWFMQA editing purposes.) 
NOTE: During the Version H conversion this field was populated with data throughout history (back to service year 1991.) 
8 DIGITS UNSIGNED 
DB2 ALIAS: NCH_BENE_DSCHRG_DT 
SAS ALIAS: DSCHRGDT STANDARD ALIAS: NCH_BENE_DSCHRG_DT TITLE ALIAS: DISCHARGE_DT EDIT-RULES: YYYYMMDD DERIVATION: DERIVED FROM: NCH_PTNT_STUS_IND_CD CLM_THRU_DT DERIVATION RULES: Based on the presence of patient discharge status code not equal to 30 (still patient), move the claim thru date to the NCH_BENE_DSCHRG_DT. 
SOURCE: NCH QA Process  

HHA Claim Demonstration ID Count

Variable Name : HHDEMCNT

Label :  HHA Claim Demonstration ID Count 

A placeholder field (effective with Version H) for storing the count of the number of Health PlanIDs reported on the HHA 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: HHA_CLM_PAYERID_CNT. 1 DIGIT UNSIGNED 

DB2 ALIAS: HHA_PLANID_CNT 

SAS ALIAS: HHPLANNT 

STANDARD ALIAS: HHA_CLM_HLTH_PLANID_CNT EDIT-RULES: RANGE: 0 TO 3 SOURCE: NCH 

Variable Name : HHDEMCNT

Label :  HHA Claim Demonstration ID Count

Effective with Version H, the count of the number of claim demonstration IDs reported on an HHA 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. 1 DIGIT UNSIGNED

 DB2 ALIAS: HHA_DEMO_ID_CNT 

SAS ALIAS: HHDEMCNT 

STANDARD ALIAS: HHA_CLM_DEMO_ID_CNT EDIT-RULES: RANGE: 0 TO 5 

SOURCE: NCH 

Variable Name : HHDGNCNT

Label :  HHA Claim Diagnosis Code Count

The count of the number of diagnosis codes (both principal and other) reported on an HHA claim. The purpose of this count is to indicate how many claim diagnosis trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_DGNS_CD_CNT 

SAS ALIAS: HHDGNCNT 

STANDARD ALIAS: HHA_CLM_DGNS_CD_CNT EDIT-RULES: RANGE: 0 TO 10 COMMENT: Prior to Version H this field was named: CLM_OTHR_DGNS_CD_CNT and the principal was not included in the count. 

 SOURCE: NCH

Variable Name : HHCONCNT

Label :  HHA Claim Related Condition Code Count

The count of the number of condition codes reported on an HHA claim. The purpose of this count is to indicate how condition code trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_COND_CD_CNT 

SAS ALIAS: HHCONCNT 

STANDARD ALIAS: HHA_CLM_RLT_COND_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_COND_CD_CNT. 

SOURCE: NCH 

Variable Name : HHOCRCNT

Label :  HHA Claim Related Occurrence Code Count

The count of the number of occurrence codes reported on an HHA claim. The purpose of this count is to indicate how many occurrence code trailers are present. 2 DIGITS UNSIGNED 

DB2 ALIAS: HHA_RLT_OCRNC_CNT SAS ALIAS: HHOCRCNT 

STANDARD ALIAS: HHA_CLM_RLT_OCRNC_CD_CNT EDIT-RULES: RANGE: 0 TO 30 COMMENT: Prior to Version H this field was named: CLM_RLT_OCRNC_CD_CNT. 

SOURCE: NCH 

Claim Total Charge Amount

Variable Name : TOT_CHRG

Label :  Claim Total Charge Amount

Effective with Version G, the total charges for all services included on the institutional claim.This field is redundant with revenue center code 0001/total charges. 9.2 DIGITS SIGNED 
DB2 ALIAS: CLM_TOT_CHRG_AMT 
SAS ALIAS: TOT_CHRG 
STANDARD ALIAS: CLM_TOT_CHRG_AMT 
TITLE ALIAS: CLAIM_TOTAL_CHARGES 
COMMENT: Prior to Version H the size of this field was S9(7)V99. 
SOURCE: CWF  

Variable Name : HHEDCNT

Label :  HHA NCH Edit Code Count

The count of the number of edit codes annotated to the HHA claim during the HCFA's CWFMQA process. The purpose of this count is to indicate how many claim edit trailers are present. 2 DIGITS UNSIGNED 
DB2 ALIAS: HHA_EDIT_CD_CNT 
SAS ALIAS: HHEDCNT 
STANDARD ALIAS: HHA_NCH_EDIT_CD_CNT 
COMMENT: Prior to Version H this field was named: CLM_EDIT_CD_CNT. 
SOURCE: NCH 

Variable Name : HHPATCNT

Label :  HHA NCH Patch Code Count

Effective with Version H, the count of the number of HCFA patch codes annotated to the home health claim during the Nearline maintenance process. The purpose of this count is to indicate how many NCH patch trailers are present. NOTE1: During the Version H conversion this field was populated with data throughout history (back to service year 1991). NOTE2: Effective with Version 'I' the number of possible occurrences was reduced to 30. Prior to Version 'I' the number of possible occurrences was 99. 2 
DIGITS UNSIGNED 
DB2 ALIAS: HHA_PATCH_CD_CNT 
SAS ALIAS: HHPATCNT 
STANDARD ALIAS: HHA_NCH_PATCH_CD_I_CNT SOURCE: NCH 

Variable Name : HHMCOCNT

Label :  HHA MCO Period Count

Effective with Version H, the count of the number of Managed Care Organization (MCO) periods reported on an home health agency 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. 1 DIGIT UNSIGNED 
DB2 ALIAS: HHA_MCO_PRD_CNT 
SAS ALIAS: HHMCOCNT 
STANDARD ALIAS: HHA_MCO_PRD_CNT EDIT-RULES: RANGE: 0 TO 2 
SOURCE: NCH 

Variable Name : HHPLANNT

Label :   HHA Claim Health PlanID Count

A placeholder field (effective with Version H) for storing the count of the number of Health PlanIDs reported on the HHA 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: HHA_CLM_PAYERID_CNT. 1 DIGIT UNSIGNED 
DB2 ALIAS: HHA_PLANID_CNT 
SAS ALIAS: HHPLANNT 
STANDARD ALIAS: HHA_CLM_HLTH_PLANID_CNT EDIT-RULES: RANGE: 0 TO 3 
SOURCE: NCH