Chapter IV: Inquiries Submenu (01)
Beneficiary/CWF (10)
Purpose
The purpose of the beneficiary screens is to provide access to all beneficiaries contained on the eligibility file. The provider can use this file to verify beneficiary data.
The first two screens of this option are Beneficiary Inquiry screens.
The remaining pages are CWF records. The CWF screens are highly recommended for verifying beneficiary data.
To access the Beneficiary/CWF option from the FISS online Inquiries submenu, type ‘10’ at the Enter Menu Selection:prompt, then press the <Enter>key.
Upon selecting the Beneficiary/CWF Option, the Initial Eligibility Detail Inquiry Screen is available:
To view the Eligibility Detail housed within the Beneficiary/CWF option, key the beneficiary’s information in the following FISS fields and press the <Enter> key.
- MID
- LN (last name)
- FI (first initial)
- SEX (M – male; F – female)
- DOB (date of birth)
- ELIG FROM (from date of service)
- ELIG THRU (thru date of service)
After entering the beneficiary’s information, the FISS Eligibility Detail Screens are available:
| Field | Description |
|---|---|
| MID | Medicare ID number |
| CURR XREF HIC | Current cross reference Medicare number – If the Medicare number has changed for the beneficiary/patient, this field represents the most recent number (as returned by CWF). The Medicare number entered in the HIC field has been changed to this Medicare number. If there is a Medicare number in this field, it is the number that should be used for billing. |
| PREV XREF HIC | Not used in DDE |
| TRANSFER HIC | Not used in DDE |
| C-IND | Century indicator – Tells the system what century to use with the birth date to determine the beneficiary’s age. For example, if the beneficiary’s date of birth was reported as 01/21/88, and the century indicator was an ‘8,’ the age would be calculated based on 1888. If the century indicator is ‘9,’ then the age would be calculated based upon 1988. |
| LTRDAYS | Lifetime reserve days remaining |
| LN | Beneficiary last name |
| FN | Beneficiary first name |
| MI | Beneficiary middle initial |
| SEX | Beneficiary sex |
| DOB | Date of birth – Reported in MMDDYYYY format |
| DOD | Date of death – If one has been received by CWF. Reported in MMDDYY format |
| ELIG FROM | From date of service – Reported in MMDDYY format |
| ELIG THRU | Thru date of service – Reported in MMDDYY format |
| ADDR | Beneficiary street address |
| CITY | Beneficiary city of residence |
| ST | Beneficiary state of residence |
| ZIP | Beneficiary ZIP Code |
Current Entitlement
| Field | Description |
|---|---|
| PART A EFF DT | Effective date of Part A current entitlement in MMDDYY format |
| TERM DT | Termination Date Part A entitlement was terminated in MMDDYY format |
| PART B EFF DT | Effective date of Part B current entitlement in MMDDYY format |
| TERM DT | Termination Date Part B entitlement was terminated in MMDDYY format |
Benefit Period Data
| Field | Description |
|---|---|
| FRST BILL DT | Date of earliest billing action in MMDDYY format |
| LST BILL DT | Date of latest billing action in MMDDYY format |
| HSP FULL DAYS | Full inpatient hospital days remaining in current benefit period |
| HSPPART DAYS | Inpatient hospital coinsurance days remaining in current benefit period |
| SNF FULL DAYS | Full inpatient SNF days remaining in current benefit period |
| SNF PART DAYS | Inpatient coinsurance SNF days remaining in current benefit period |
| INP DED REMAIN | Inpatient deductible remaining to be met in the current benefit period |
| BLDDED PNTS | Inpatient Part A blood deductible pints remaining to be met in the current benefit period |
Psychiatric
| Field | Description |
|---|---|
| PSY DAYS REMAIN | Number of lifetime psychiatric days remaining (based upon a maximum benefit of 190 days) |
| PRE PHY DAYS USED | Number of pre-entitlement days used when the beneficiary was in a psychiatric hospital that reduce the number of regular days available to the beneficiary during their initial benefit period |
| PSY DIS DT | Psychiatric discharge date – Last discharge date from a psychiatric hospital for this beneficiary in MMDDYY format |
| INTRM DT IND | Interim date indicator – One-position indicator showing an interim date for psychiatric services Valid values Y = Date is through date of an interim bill; utilization day N = Discharge date; not a utilization day |
Use the <F8> key to move forward to FISS Eligibility Detail Screen 2.
| Field | Description |
|---|---|
| RI | CWF Inquiry Type Valid value = 1 (CWF FISS Inquiry) |
| MAMMO DT | Date of last mammogram in CCYYMMDD format |
Part B Data
| Field | Description |
|---|---|
| SRV YR | Reports the year to which the data applies, in YY format. |
| MEDICAL EXPENSE | Amount applied to the Part B cash deductible for the service year. |
| BLD DED REM | Number of pints remaining to be applied to the beneficiary’s calendar year blood deductible. |
| PSY EXP | Psychiatric expense – Amount of reasonable charges applied toward the beneficiary’s yearly maximum. |
| SRV YR | Reports the year to which the data applies. |
| BLD DED | Field not used in DDE |
| CSH DED | Field not used in DDE |
Plan Data
| Field | Description |
|---|---|
| ID CD | Plan Identification code of the HMO ‑ Five-position field defined as the following: Position 1 = H (constant) Position 2 and 3 = Two-digit state code Position 4 and 5 = Two-digit code assigned to the HMO |
| OPT CD | Option code for HMO which indicates whether the services are restricted or unrestricted. Valid Values 1 = Unrestricted; intermediary to process all Part A and Part B provider claims 2 = Unrestricted; HMO to process claims for directly provided services and for services from providers with effective arrangements. Intermediary to process all other claims A = Restricted; intermediary to process all Part A and Part B claims B = Restricted; HMO to process claims only for directly provided services C = Restricted; HMO to process all claims |
| EFF DT | Effective date of a beneficiary’s HMO enrollment |
| CANC DT | Termination date of a beneficiary’s HMO enrollment |
Hospice Data
| Field | Description |
|---|---|
| PERIOD | Hospice period – Identifies the specific hospice election period. Four different periods may be displayed, depending upon the number of election periods that the beneficiary may have already used. The valid values are 1, 2, 3 or 4. |
| 1ST DT | First start date – Displays the start date of beneficiary’s effective period with the first hospice provider that the beneficiary chose during the period. |
| RI | CWF Inquiry Type Valid value = 1 (CWF FISS Inquiry) |
| PROVIDER | Provider number – Identifies the number of the Medicare hospice provider. |
| INTER | Intermediary number – Identifies the intermediary number for the hospice provider. |
| OWNER CHANGE ST DT | Change of ownership start date – Displays the start date of a change of ownership for the first provider, within the period. |
| 2ND ST DT | Second start date – Displays start date of the beneficiary’s effective period with the second hospice provider that the beneficiary chose to use during period. |
| TERM DT | Termination date – Displays the termination date of the beneficiary’s effective period. |
| OWNER CHANGE ST DT | Change of ownership start date – Displays the start date of a change of ownership for the second provider, within the period. |
| 1ST BILL DATE | First date of service billed under the hospice election |
| LST BILL DATE | Last date of service billed under the hospice election |
| DAYS BILLED | Cumulative number of days billed to date for the beneficiary under the hospice election |
Use the <F8> key to access CWF on the next page. CWF contains multiple pages of beneficiary eligibility data, starting with Preventive Services screens.
One way for Medicare beneficiaries to stay healthy is to use preventive services provided by doctors and health care providers. Preventive services can find health problems early when treatment works best. This information will display when the next eligible date is available for preventive services covered by Medicare for a given beneficiary.
All eligibility fields will report the next eligible date or a three- or four-position alpha code to indicate the reason why there is no eligibility date. Valid values include:
-
- PTB – Beneficiary not entitled to Part B
- RCVD – Beneficiary already received service
- DOD – Beneficiary not eligible due to DOD
- GDR – Beneficiary not eligible due to gender
- AGE – Beneficiary not eligible due to age
- SRV – Beneficiary not eligible for the service
- VAC – Beneficiary already vaccinated
- 0000 – Service not applicable
| Field | Description |
|---|---|
| MID | Medicare ID number |
| NM | Last name |
| IT | First initial |
| DB | Date of birth |
| SX | Sex (M – male; F – female) |
| PRVN SERVC | Category of one or more Preventive Service HCPCS/CPT procedure codes |
| TECH D | Technical date – next date beneficiary is eligible to receive technical component of preventive service or indication code |
| PROF D | Professional date – next date beneficiary is eligible to receive professional component of preventive service or indication code |
| CARD/80061 | Screening for CVD HCPCS code 80061 |
| CARD/82465 | Screening for CVD HCPCS code 82465 |
| CARD/83718 | creening for CVD HCPCS code 83718 |
| CARD/84478 | Screening for CVD HCPCS code 84478 |
| COLO/G0104 | Colorectal screening HCPCS code G0104 |
| COLO/G0105 | Colorectal screening HCPCS code G0105 |
| COLO/G0106 | Colorectal screening HCPCS code G0106 |
| COLO/G0120 | Colorectal screening HCPCS code G0120 |
| COLO/G0121 | Colorectal screening HCPCS code G0121 |
| FOBT/G0328 | Fecal occult blood test HCPCS code G0328 |
| FOBT/82270 | Fecal occult blood test CPT code 82270 |
| IPPE/G0344 | Initial preventive physical examination HCPCS code G0344 |
| IPPE/G0366 | Initial preventive physical examination HCPCS code G0366 |
| IPPE/G0367 | Initial preventive physical examination HCPCS code G0367 |
| IPPE/G0368 | Initial preventive physical examination HCPCS code G0368 |
| DIAB/82947 | Diabetes screening HCPCS code 82947 |
| DIAB/82950 | Diabetes screening HCPCS code 82950 |
| DIAB/82951 | Diabetes screening HCPCS code 82951 |
| PCBE/G0101 | Pelvic and clinical breast examination HCPCS code G0101 |
| PROS/G0102 | Prostate screening HCPCS code G0102 |
| PROS/G0103 | Prostate screening HCPCS code G0103 |
| PAPT/Q0091 | Screening Pap test |
| GLAU | Glaucoma screening |
| MAMM | Screening Mammography |
| PAPT | Screening Pap Test |
| HIBC/G0445 | High intensity behavioral counseling to prevent sexually transmitted infections face to face HCPCS G0445 |
| HBV | Hepatitis B Virus Screening |
| SETS/93668 | Supervised Exercise Therapy |
| AAA/G0389 | Screening for Abdominal aortic aneurysm HCPCS code G0389 |
| PTWR/G9143 | Pharmacogenomic testing HCPCS code G1943 |
| IPPE/G0402 | Initial preventive physical examination face to face visit HCPCS code G0402 |
| IPPE/G0403 | Electrocardiogram, routine ECG with 12 leads performed as a screening with Initial preventive physical examination HCPCS code G0403 |
| IPPE/G0404 | Electrocardiogram, routine ECG with 12 leads; tracing only performed as a screening with Initial preventive physical examination HCPCS code G0404 |
| IPPE/G0405 | Electrocardiogram, routine ECG with 12 leads; interpretation report only performed as a screening with Initial preventive physical examination HCPCS code G0405 |
| PULM/G0424 | Pulmonary rehabilitation, including exercise (includes monitoring), one hour per session, up to two sessions per day HCPCS code G0424 |
| CR | Cardiac rehabilitation |
| ICR | Intensive cardiac rehabilitation |
| AWV/G0438 | Annual wellness visit; includes a PPPS, initial visit HCPCS code G0438 |
| AWV/G0439 | Annual wellness visit; includes a PPPS, subsequent visit HCPCS code G0439 |
| BEHV/G0447 | Face to face behavioral counseling for obesity, 15 minutes HCPCS code G0447 |
Use the <F6> key to scroll forward on the Preventive Services page. Additional services and next eligible dates are shown:
| Field | Description |
|---|---|
| TELH/99231 | Subsequent hospital care, per day, for the evaluation and management of a patient HCPCS code 99231 |
| TELH/99232 | Subsequent hospital care, per day, for the evaluation and management of a patient HCPCS code 99232 |
| TELH/99233 | Subsequent hospital care, per day, for the evaluation and management of a patient CPT code 99233 |
| TELH/99307 | Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99307 |
| TELH/99308 | Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99308 |
| TELH/99309 | Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99309 |
| TELH/99310 | Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99310 |
| BEHV/G0442 | Annual alcohol misuse screening, 15 minutes HCPCS code G0442 |
| BEHV/G0443 | Brief face to face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443 |
| BEHV/G0444 | Annual depression screening, 15 minutes HCPCS code G0444 |
| BEHV/G0446 | Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face to face annual, 15 minutes HCPCS code G0446 |
| BONE/77078 | Bone density testing, Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) CPT code 77078 |
| BONE/77080 | Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg., hips, pelvis, spine) CPT code 77080 |
| BONE/77081 | Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites;appendicular skeleton (peripheral) (eg, radius, wrist, heel) CPT code 77081 |
| BONE/76977 | Bone density testing, Ultrasound bone density measurement and interpretation, peripheral site(s), a method CPT code 76977 |
| BONE/G0130 | Bone density testing, Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) HCPCS code G0130 |
| BEHV/G0473 | Behavioral counseling for obesity HCPCS code G0473 |
| HCAS/G0472 | Hepatitis C antibody, screening, for individual at high risk and other covered indication(s) code G0472 |
| BONE/77085 | Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment CPT code 77085 |
| COCS | Cervical cancer screening |
| LDCT/G0297 | Low Dose CT scan for lung cancer screening code G0297 |
| HPVS/G0476 | Screening for HPV HCPCS code G0476 |
| HIVS | HIV Screening |
| BONE/0508T | Ultrasound measurement of bone density in shin bone |
| BONE/0554T | Bone strength and fracture risk assessment: retrieval and transmission of CT scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report |
| BONE/0555T | Bone strength and fracture risk assessment: retrieval and transmission of CT scan data only |
| BONE/0556T | Bone strength and fracture risk assessment: assessment of bone strength and fracture risk and bone mineral density |
| BONE/0557T | Bone strength and fracture risk assessment: interpretation and report |
| BONE/0558T | CT scan for biomechanical computed tomography analysis |
| ABPM/93784 | Ambulatory Blood Pressure Monitoring |
Use the <F8> key to continue to the next page of the CWF.
| Field | Description |
|---|---|
| CLAIM | Medicare number |
| NAME | Beneficiary’s first initial and last name |
| D.O.B. | Date of birth |
| SEX | Sex code: U = Unknown M = Male F = Female |
| APP DT | Not used |
| REASON CD | Reason code: 1 = Status inquiry 2 = Inquiry relating to an admission |
| DATE/TIME | Date and time stamp YYDDDHHMMSS |
| REQ ID | Not used |
| DISP CD | Disposition code: 01 = Part A inquiry approved; beneficiary has never used Part A services 02 = Part A inquiry approved; beneficiary has some prior Part A utilization 03 = Part A inquiry rejected 04 = Qualified approval—may require further investigation 05 = Qualified approval—this inquiry begins new benefit period |
| TYPE | Type of reply: 3 = Accept |
| CENT D.O.B. | Century indicator for date of birth: 8 = 18th century 9 = 19th century |
| D.O.D. | Date of death if one has been received from CWF |
| A: CURR-ENT DT | Current Part A entitlement date |
| A: TERM DT | Current Part A termination date |
| A: PRI-ENT DT | Prior Part A entitlement date |
| A: TERM DT | Prior Part A termination date |
| B: CURR-ENT DT | Current Part B entitlement date |
| B: TERM DT | Current Part B termination date |
| B: PRI-ENT DT | Prior Part B entitlement date |
| B: TERM DT | Prior Part B termination date |
| LIFE: RSRV | Lifetime reserve days remaining |
| LIFE: PSYCH | Lifetime PSYCH days remaining |
Benefit Period Data (Current and Prior)
| Field | Description |
|---|---|
| FRST BILL DT | Date of earliest billing action |
| LST BILL DT | Date of latest billing action |
| HSP FULL DAYS | Full inpatient hospital days remaining in current benefit period |
| HSPPART DAYS | Inpatient hospital coinsurance days remaining in the current benefit period |
| SNF FULL DAYS | Full inpatient SNF days remaining in current benefit period |
| SNF PART DAYS | Inpatient SNF coinsurance days remaining in the current benefit period |
| INP DED REMAIN | Inpatient deductible remaining to be met in the current benefit period |
| BLD DED PNTS | Inpatient Part A blood deductible pints remaining to be met in the current benefit period |
| CURR B: YR | Indicates the year to which the information pertains |
| CASH | Part B cash deductible remaining to be met |
| BLOOD | Part B blood deductible remaining to be met |
| PSYCH | PSYCH Part B limit remaining to be met |
| PT | Part B physical therapy limit remaining to be met |
| OT | Part B occupational therapy limit remaining to be met |
| PRIR B: YR | Indicates the prior Part B benefit year |
| CASH | Cash deductible remaining to be met for prior Part B benefit year |
| BLOOD | Blood deductible remaining to be met for prior Part B benefit year |
| PSYCH | Psychiatric limit remaining for prior Part B benefit year |
| PT | Physical therapy limit applied YTD for prior Part B benefit year |
| OT | Occupational therapy limit applied YTD for prior Part B benefit year |
Use the <F8> key to continue to the next page of the CWF.
| Field | Description |
|---|---|
| DATA IND | Indicators Position 1 – Part B buy-in 0 = Does not apply 1 = State buy-in involved Position 2 – Alien indicator 0 = Does not apply 1 = Alien nonpayment, provision may apply Position 3 – Psychiatric pre-entitlement 0 = Does not apply 1 = Psychiatric pre-entitlement reduction applied Position 4 – Reason for entitlement 0 = Normal entitlement 1 = Disability (DIB) 2 = ESRD 3 = Has or had ESRD, but current DIB 4 = Working age, but has or had ESRD 8 = Has or had ESRD and is covered under premium Part A 9 = Covered under premium Part A Position 5 – Part A buy-in 0 = No Part A buy-in 1 = Part A buy-in applies Position 6 – Rep Payee indicator 0 = Does not apply 1 = Selected for general enrollment period (GEP) contact 2 = Has rep payee 3 = Both conditions apply |
| NAME | Full name of beneficiary in last name, first name, middle initial format |
| ZIP | Beneficiary ZIP code |
| PLAN ENR CD | Indicates the number of periods of enrollment: 0 = 0 1 = 1 2 = 2 3 = more than 2 |
| CURR PLAN: | Current plan |
| CURR: ID | Five-position current plan identification number: 1 = H (constant) 2 and 3 = state code 4 and 5 = Plan number |
| OPT | Option code– Describes whether the plan is restricted or unrestricted. Unrestricted 1 = MAC processes all Part A and B provider bills 2 = HMO plan processes bills for directly provided services and for services from providers with effective arrangements Restricted A = MAC processes all Part A and B bills B = HMO plan processes bills only for directly provided services C = HMO plan to process all bills |
| ENR | Enrollment Date– Effective date of current entitlement |
| TERM | Termination date of current enrollment |
| PRIR PLAN: | Prior plan |
| PRI ID | Identifies prior plan– Five-position field: Position 1 = H or 1–9 Position 2 and 3 = state code Position 4 and 5 = plan number within the state |
| OPT | Identifies whether the prior plan services are restricted or unrestricted. Unrestricted 1 = MAC processes all Part A and B claims 2 = HMO processes all directly provided services Restricted A = MAC processes all Part A & B claims B = HMO processes all directly provided services C = HMO processes all claims |
| ENR | Enrollment date of prior plan |
| TERM | Identifies prior plan termination date |
| OTHER ENTITLEMENTS OCCURRENCE CD/DATE | Identifies first two occurrence codes and dates indicating another federal program or insurance as primary payer. Occurrence code – One-position field 1 = Workers’ Compensation 2 = Black lung A = Working-aged beneficiary or spouse B = ESRD beneficiary in coordination period and covered by EGHP C = Medicare conditional payment pending final resolution D = Automobile no-fault or other liability insurance E = Workers’ Compensation and/or black lung F = Veteran’s administration, public health, or other federal agency program G = Working disabled beneficiary or spouse H = Black lung I = Veteran’s Administration Date– Six-position field according to occurrence code 1 or 2 = Effective date of program A–I = Date of previous claim where Medicare is secondary |
| ESRD CD/DATE | End-stage renal disease code and date– Displays method selection information for dialysis patients: 1 = Method 1 2 = Method 2 Date = Month and year of selection (MMYY format) This field displays two occurrences of data |
| CAT DATA: PSYCH | The number of psychiatric days remaining (based on a maximum benefit of 190 days) |
| CAT DATA: DISCHG | Discharge date from inpatient stay in a psychiatric hospital |
| CAT DATA: IND | Identifies discharge date: 0 = initialized 1 = interim |
| CAT DATA: DAYS USED | Psychiatric days used |
| CAT DATA: BLOOD | Identifies number of blood pints carried over from 1988 to 1989 |
| YR | Reports the year to which the data applies |
| APP | Identifies whether a December inpatient stay was applied to the current year deductible |
| MET | Identifies amount of inpatient deductible to be met |
| BLD | Blood deductible pints remaining to be met |
| CO | SNF coinsurance days available |
| FL | SNF full days available |
| FRM | Date of earliest billing action for this benefit period |
| TO | Date of latest billing action for this benefit period |
| IND | Yearly data indicators—three positions. Position 1 0 = Not used 2 = Clerical involvement 3 = Christian Science/SNF usage 4 = Both 1 and 2 Position 2 0 = Not used 1 = Through date is interim Positions 3 and 4 For future use |
| INT | Intermediary number |
| ADM | Date of admission |
| FRM | Statement covers from date |
| TO | Statement covers to date |
| APP | Inpatient deductible applied |
| ADJ IND | Type of adjustment: 0 = No adjustment 1 = Downward adjustment 2 = Upward adjustment |
| CALC DED | Calculated deductible—amount of inpatient deductible calculated |
| CMS DT | Date that transaction was processed by CMS |
Use the <F8> key to continue to the next page of the CWF.
| Field | Description |
|---|---|
| HH-REC | Home health record |
| CN | Medicare number |
| NM | Last name |
| IT | First initial |
| DB | Date of birth |
| SX | Sex (M – male; F – female) |
| TECHCOM | Identifies the date of mammography screening interpreted by a technician |
| PROCOM | Identifies the date of mammography screening requiring interpretation by a physician |
| MAMMO RSK | Indicator that describes beneficiary risk: Y = High-risk N = Not at high-risk |
| MAMMO DATES | Date of last screening mammogram (up too three may be listed) |
Transplant Information
| Field | Description |
|---|---|
| COV IND | Indicates covered or noncovered transplant: C = Covered N = Noncovered |
| TRAN IND | Indicates type of transplant done: 1 = Allogeneic bone marrow 2 = Autologous bone marrow H = Heart K = Kidney L = Liver |
| DIS DATE | Date of discharge from hospital inpatient stay in which transplant procedure was done |
| EPISODE START | Identifies the start date of an episode |
| EPISODE END | Identifies the end date of an episode |
| DOEBA | Identifies the first service date of the HH PPS period |
| DOLBA | Identifies the last service date of the HH PPS period |
Use the <F8> key to continue to the next page of the CWF. Please note: beneficiary hospice information is available for up to four hospice election periods.
| Field | Description |
|---|---|
| PERIOD | Hospice period – Identifies the specific hospice election period. Four different periods may be displayed, depending upon the number of election periods that the beneficiary may have already used. Valid values are 1, 2, 3, or 4. |
| 1ST ST DATE | First start date – Displays the first start date of the beneficiary’s effective period with the first hospice provider that the beneficiary chose during the period |
| PROV | Provider number – Identifies the number of the Medicare hospice provider |
| INTER | Intermediary number – Identifies the intermediary number of the hospice provider |
| OWNER CHANGE ST DATE | Change of ownership start date – Displays the start date of a change of ownership for the first provider, within the period |
| 2ND ST DATE | Second start date – Displays the start date of the beneficiary’s effective period with the second hospice provider that the beneficiary chose to use during the period |
| TERM DATE | Termination date – Displays the termination date of the beneficiary’s election period |
| 1ST BILLED DT | First date of service billed under the hospice election |
| LAST BILLED DT | Last date of service billed under the hospice election |
| DAYS BILLED | The cumulative number of days billed to date for the beneficiary under the hospice election |
| REVO IND | Indicates whether hospice coverage revocation occurred: 0 = No revocation 1 = Revocation of benefits for this election period |
Use the <F8> key to continue to the next page of the CWF. Please note: the SMOKING AND TOBACCO USE CESSATION COUNSELING SERVICES screen will display only if CWF has data on the auxiliary file to be returned for the beneficiary’s Medicare number.
| Field | Description |
|---|---|
| MID | Medicare ID number |
| LN | Last name up to six letters |
| FI | First initial |
| DOB | Date of birth MM/DD/YYYY |
| SEX | Sex code (M – male; F – female) |
| COUNSELING PERIOD | Refers to five years of data that will be displayed—will display numerics of 1–5 years |
| TOTAL SESSIONS | Number of sessions billed |
| HCPCS | HCPCS code – Either G0375 or G0376 |
| FROM | Displayed as MM/DD/CCYY |
| THRU | Displayed as MM/DD/CCYY |
| PER | Period refers to five years of data that will be displayed and will contain a 1–5 |
| QT | Quantity– Refers to number of services billed for each date |
| TP | Claim type O = Outpatient B = Part B |
Use the <F8> key to continue to the next page of the CWF.
| Field | Description |
|---|---|
| EFFECTIVE DATE | Effective date of coverage |
| SUBSCRIBER NAME | Name of subscriber |
| TERMINATION DATE | Termination date of coverage |
| POLICY NUMBER | Subscriber policy number |
| MSP CODE | Code that identifies the Medicare Secondary Payer (MSP) program A = Working aged (value code 12) B = ESRD beneficiary in coordination period (value code 13) C = Conditional Medicare payment D = Auto no-fault or any liability insurance (value code 14) E = Workers’ Compensation (WC) (value code 15) F = Public Health Services (PHS) or other federal agency (value code 16) G = Disabled (value code 43) H = Black lung (value code 41) I = Veteran’s Administration (value code 42) L = Liability (value code 47) W = WC Set-aside Z = Medicare Part A |
| INSURER TYPE | Type of primary insurer A = Insurance B = group health plan (GHP) HMO D = Third Party Administrator (TPA) arrangement under an Application Services Organization (ASO) contract E = TPA arrangement with stop loss insurance F = Self insured/self administered G = Collectively bargained health and welfare fund H = Multiple employer health plan with at least one employer who has more than 100 full and/or part-time employees I = Multiple employer health plan with at least one employer who has more than 20 full and/or part-time employees J = Hospital services only plan K= Medical services only plan M = Medicare supplement |
| PATIENT RELATIONSHIP | Subscriber relationship to patient: 01 = Spouse 18 = Self 19 = Child 20 = Employee 21 = Unknown 39 = Organ donor 40 = Cadaver donor 53 = Life partner G8 = Other relationship |
| REMARKS CODES | Contractor information to assist in additional development—two-position field (values are determined by the contractor) |
Insurer Information
| Field | Description |
|---|---|
| NAME | Name of insurer |
| GROUP NO | Group number |
| ADDRESS | Address of insurer |
| NAME | Name of insurance group |
Employer Data
| Field | Description |
|---|---|
| NAME | Name of employer |
| EMPLOYEE ID | Identification number assigned by the employer |
| ADDRESS | Employer’s address |
| EMPLOYEE INFO | To whom the employment data applies: P = Patient S = Spouse M = Mother F = Father |
| ADDRESS | Employer’s address |
Use the <F8> key to continue to the next page of the CWF. Map175Q is a Radiation Oncology (RO) Model screen to show the Prospective Bundled Payments for Radiation Oncology Model (PBRO) auxiliary file information.
| Field | Description |
|---|---|
| PROF-HCPCS | Professional RO Model HCPCS codes billed on the claim; five-position alphanumeric field. |
| ACT-SOE-DT | Start date of the RO Model Episode; six-position numeric field in MMDDYY format. |
| ACT-EOE-DT | End date of the RO Model Episode; six-position numeric field in MMDDYY format. |
| PROF-DIAG-CD | RO Model Diagnosis Code billed on the claim; eight-position alphanumeric field. |
| RENDERING-NPI | NPI of the Rendering Physician on the claim; 10-position alphanumeric field. |
| TAX-ID-NBR | Professional Participant billed on the claim; 10-position alphanumeric field. |
| TECH-HCPCS | Facility/Technical RO Model-specific HCPCS code billed on the claim; five-position alphanumeric field. |
| TEMP-SOE-DT | Temporary start of the episode; six-position numeric field in MMDDYY format. |
| TEMP-EOE-DT | Temporary end of the episode; six-position numeric field in MMDDYY format. |
| TECH-DIAG-CD | Technical First Diagnosis Code or Line Item Diagnosis Code billed on the claim; eight-position alphanumeric field. |
| CCNTIN | Facility/Technical participant billed on the claim; 13-position alphanumeric field. |
Revised 8/16/2023