Claim Page 01 — Entering a Notice of Election (NOE)
Claim Page 01 (Map 1711) contains general patient information, condition codes, occurrence codes, occurrence span codes, and value codes.
Begin entering data on Claim Page 01 and continue until the necessary fields are completed. Use the key and table below to determine what fields are required and what information to enter.
Key:
- RED = Required field
- BLUE = Optional field
- GREEN = Conditional field, dependent on the type of claim
- PURPLE = System generated field
- BLACK = Not required field
Field Descriptions for Claim Page 01 – Map 1711
| Field Name / Requirement | Description | ||||||
|---|---|---|---|---|---|---|---|
| HIC Required |
Enter the beneficiary’s Health Insurance Claim Number (HICN) | ||||||
| TOB Required |
Type of bill (system generated; you may
need to change this depending on the TOB you are entering).
|
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| OSCAR Accepted until May 23, 2008 |
Medicare provider number. FISS will automatically plug this field with your OSCAR number. | ||||||
| NPI Required |
Enter your National Provider Identifier. | ||||||
| PAT CNTL # Optional |
Up to 20 digits are available for you to enter your internal account number for tracking purposes. This number will display on your Remittance Advice or your Electronic Remittance Advice. | ||||||
| STMT DATES FROM Required |
Enter the FROM date of this hospice election. A TO date is not required on NOEs. | ||||||
| LAST Required |
Enter the beneficiary’s last name exactly as it appears on the Medicare card or ELGA/ELGH page 1. |
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| FIRST Required |
Enter the beneficiary’s first name exactly as it appears on the Medicare card or ELGA/ELGH page 1. |
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| MI Optional |
Enter the beneficiary’s middle initial. |
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| DOB Required |
Enter the beneficiary’s date of birth (MMDDCCYY). |
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| ADDR 1-6 Required |
Enter the beneficiary’s full mailing address, including street name and number, post office box number or RFD, city and state. |
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| ZIP Required |
Enter the beneficiary’s zip code. |
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| SEX Required |
Enter the beneficiary’s
gender using the appropriate alpha character. |
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| MS Optional |
Beneficiary’s marital status. |
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| ADMIT DATE Required |
Enter the effective date of the hospice election. On NOEs, this date must match the FROM date. |
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| HR Required |
Hour of Admission—Enter
the appropriate hour of admission (based on a 24-hour clock). If
hour of admission is unknown, use 01. |
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| OCC CDS/DATES Required |
Occurrence code 27 and the date of certification. |
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| FAC ZIP Required |
Facility zip code of the provider or the subpart (5- or 9- digit). |
Page last updated: March 27, 2008
