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 Agency

Variable Name : RACE

Label :  Beneficiary Race Code

The race of a beneficiary. 

DA3 ALIAS: RACE_CODE 

DB2 ALIAS: BENE_RACE_CD 

SAS ALIAS: RACE 

STANDARD ALIAS: BENE_RACE_CD 

SYSTEM ALIAS: LTRACE TITLE ALIAS: 

RACE_CD 

CODES: 0 = Unknown 

1 = White 

2 = Black 

3 = Other 

4 = Asian 

5 = Hispanic 

6 = North American Native

SOURCE: SSA

Variable Name : BENE_DOB

Label :  Beneficiary Birth Date

The beneficiary's date of birth. 8 DIGITS UNSIGNED 

DB2 ALIAS: BENE_BIRTH_DT 

SAS ALIAS: BENE_DOB 

STANDARD ALIAS: BENE_BIRTH_DT 

TITLE ALIAS: BENE_BIRTH_DATE EDIT-RULES: YYYYMMDD 

SOURCE: CWF 

Variable Name : MS_CD

Label :  CWF Beneficiary Medicare Status Code

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 

SYSTEM ALIAS: LTMSC 

TITLE ALIAS: MSC 

DERIVATION: 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. 

CODES: 10 = Aged without ESRD 

11 = Aged with ESRD 

20 = Disabled without ESRD

21 = Disabled with ESRD 

31 = ESRD only COMMENT: 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  

Variable Name : SURNAME

Label :   Claim Patient 6 Position Surname

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 

SOURCE: CWF 

Variable Name : FRSTINIT

Label :    Claim Patient 1st Initial Given Name

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 

SOURCE: CWF 

CWF Claim Assigned Number

Variable Name : ASGN_NUM

Label :  CWF Claim Assigned Number

Effective with Version H, the number assigned to an institutional claim record by CWF (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 spaces in this field. 

DB2 ALIAS: CWF_CLM_ASGN_NUM 

SAS ALIAS: ASGN_NUM 

STANDARD ALIAS: CWF_CLM_ASGN_NUM 

TITLE ALIAS: ASSIGNED_NUM

SOURCE: CWF 

Variable Name : FIBATCH

Label : CWF Transmission Batch Number

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 

SOURCE: CWF 

Variable Name : BENE_ZIP

Label : Beneficiary Mailing Contact ZIP Code 

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 

SOURCE: EDB 

Variable Name : SEX

Label : Beneficiary Sex Identification Code

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 

SYSTEM ALIAS: LTSEX 

TITLE ALIAS: SEX_CD EDIT-RULES: REQUIRED FIELD 

CODES: 

1 = Male 

2 = Female 

0 = Unknown 

SOURCE: SSA,RRB,EDB 

FI Claim Receipt Date

Variable Name : RCPT_DT 

Label :  FI Claim Receipt Date

The date the fiscal intermediary received the institutional claim from the provider.

 8 DIGITS UNSIGNED 

DB2 ALIAS: FI_CLM_RCPT_DT 

SAS ALIAS: RCPT_DT 

STANDARD ALIAS: FI_CLM_RCPT_DT 

TITLE ALIAS: RECEIPT_DT EDIT-RULES: YYYYMMDD COMMENT: Prior to Version H this field was named: FICARR_CLM_RCPT_DT. 

SOURCE: CWF

Variable Name : SCHLD_DT

Label :  FI Claim Scheduled Payment Date

The scheduled date of payment to the institu- tional provider, as reflected on the claim record transmitted 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. 8 DIGITS UNSIGNED 

DB2 ALIAS: FI_SCHLD_PMT_DT 

SAS ALIAS: SCHLD_DT 

STANDARD ALIAS: FI_CLM_SCHLD_PMT_DT 

TITLE ALIAS: SCHEDULED_PMT_DT EDIT-RULES: YYYYMMDD 

COMMENT: Prior to Version H this field was named: FICARR_CLM_PMT_DT. 

SOURCE: CWF

Variable Name : FRWRD_DT

Label :  CWF Forwarded Date

Effective with Version H, the date CWF forwarded the claim record to HCFA (used for internal editing purposes). 

NOTE: Beginning with NCH weekly process date 10/3/97 field was populated with data. Claims processed prior to 10/3/97 will contain zeroes in this field. 8 DIGITS UNSIGNED 

DB2 ALIAS: CWF_FRWRD_DT 

SAS ALIAS: FRWRD_DT 

STANDARD ALIAS: CWF_FRWRD_DT 

TITLE ALIAS: FORWARD_DT EDIT-RULES: YYYYMMDD 

SOURCE: CWF

Variable Name : FI_NUM

Label :  FI Number

The identification number assigned by HCFA to a fiscal intermediary authorized to process institutional claim records. 

DB2 ALIAS: FI_NUM 

SAS ALIAS: FI_NUM 

STANDARD ALIAS: FI_NUM 

SYSTEM ALIAS: LTFI 

TITLE ALIAS: INTERMEDIARY 

CODES: REFER TO: FI_NUM_TB IN THE CODES APPENDIX

COMMENT: Prior to Version H this field was named: FICARR_IDENT_NUM. 

SOURCE: CWF 

NCH MQA Query Patch Code

Variable Name :MQAQUERY

Label :NCH MQA Query Patch Code 

Effective with Version H, a code used (for internal editing purposes) to indicate that the CWFMQA process changed the query code submitted on the claim record. 

NOTE: Beginning with NCH weekly process date 10/3/97 field was populated with data. Claims processed prior to 10/3/97 will contain spaces in this field. 

DB2 ALIAS: MQA_QUERY_PATCH_CD 

SAS ALIAS: MQAQUERY 

STANDARD ALIAS: NCH_MQA_QUERY_PATCH_CD 

TITLE ALIAS: MQA_QUERY_PATCH_IND 

CODES: 

Y = MQA changed bill query code on a action code 6 (force action code 2) bill to a zero. (Eff. 10/12/93) 

Z = MQA changed bill query code on a action code 4 (cancel only adjustment) bill to zero. (Eff. 5/16/94) 

SOURCE: NCH QA Process 

Variable Name :DISP_CD

Label :Claim Disposition Code

Code indicating the disposition or outcome of the processingof the claim record. 

DB2 ALIAS: CLM_DISP_CD 

SAS ALIAS: DISP_CD 

STANDARD ALIAS: CLM_DISP_CD 

TITLE ALIAS: DISPOSITION_CD 

CODES: REFER TO: CLM_DISP_TB IN THE CODES APPENDIX 

SOURCE: CWF

Variable Name :EDITDISP

Label :NCH Edit Disposition Code

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 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

CODES:

 00 = No MQA errors 

10 = Possible duplicate 

20 = Utilization error 

30 = Consistency error 

40 = Entitlement error 

50 = Identification error 

60 = Logical duplicate 

70 = Systems duplicate 

SOURCE: NCH QA Process 

Variable Name :BIC_MDFY

Label :NCH Claim BIC Modify H Code

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 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

CODES: 

H = BIC submitted by CWF = HA, 

HB or HC blank = No HA, HB or HC BIC present 

SOURCE: NCH QA Process 

Variable Name :CNTY_CD

Label :Beneficiary Residence SSA Standard County Code

The SSA standard county code of a beneficiary's residence. 

 DA3 ALIAS: SSA_STANDARD_COUNTY_CODE 

DB2 ALIAS: BENE_SSA_CNTY_CD 

SAS ALIAS: CNTY_CD 

STANDARD ALIAS: BENE_RSDNC_SSA_STD_CNTY_CD 

TITLE ALIAS: BENE_COUNTY_CD EDIT-RULES: OPTIONAL: MAY BE BLANK 

SOURCE: SSA/EDB

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 car

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.