Claim Page 03 — Entering a Hospice Claim

Claim Page 03 (Map 1713) contains payer information, diagnosis/procedure code information, and physician information.

FISS Claims Screen 03, Hospice Claim Entry

Key:

RED = Required field
BLUE = Optional field
GREEN = Conditional field, depended on the type of claim
PURPLE = System generated field
BLACK = Not required field

Field Descriptions for Claim Page 03 – Map 1713

The HIC, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Name	Description
CD Required	Primary payer code. Line A reflects the primary payer, line B reflects the secondary payer, and line C reflects the tertiary payer. When Z (Medicare) is entered as a payer code, the payer name “Medicare” does not have to be entered in the “Payer” field. FISS will insert it automatically. Valid values are: 1 – Medicaid 2 – Blue Cross 3 – Other 4 – None A – Working Aged B – ESRD Beneficiary in 30-month coordination period with an EGHP C – Conditional Payment D – Auto/No-fault E – Worker’s Compensation F – Public Health Service or other Federal Agency G – Disabled H – Black Lung I – Veterans Administration L – Liability Z – Medicare
PAYER Conditionally Required	Enter the name of insurance company. Line A reflects the primary payer, line B is the secondary payer and line C is the tertiary payer.
OSCAR Required	Medicare provider number. FISS will automatically plug this field with your OSCAR number.
RI Required	Release of Information. Enter a “Y” to indicate you have a signed statement on file permitting you to release data to other organizations to adjudicate claims. An “R” indicates the release is limited or restricted. An “N” indicates no release is on file.
PRIOR PAY Conditionally Required	Prior amount paid by the beneficiary. Enter the amount collected from the patient toward deductibles and/or coinsurance.
MEDICAL RECORD NBR Optional	Beneficiary’s medical record number.
DIAGNOSIS CODES Required	Enter the ICD-9-CM diagnosis codes (9 codes maximum). Hospices may not report V-codes as the primary diagnosis on hospice claims.
ATT PHYS Required until May 23, 2008	Enter the Unique Physician Identification Number (UPIN) of the physician currently responsible for certifying the terminal illness.
NPI Required effective May 23, 2008	Enter the national provider identifier (NPI) of the certifying physician.
LN Required	Enter the last name of the certifying physician.
FN Required	Enter the first name of the certifying physician.
MI Optional	Enter the middle initial of the certifying physician (not required).
OTH PHYS Required until May 23, 2008	If the attending physician is a nurse practitioner, enter the UPIN of the nurse practitioner.
NPI Required effective May 23, 2008	Enter the NPI of the nurse practitioner. (Required effective May 23, 2008).
LN Optional	Enter the last name of the nurse practitioner.
FN Optional	Enter the first name of the nurse practitioner.
MI Optional	Enter the middle initial of the nurse practitioner (not required).

Page last updated: March 31, 2008