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i
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
Detailed Table of Contents
________________________________________________________________________
ADJUST ROUTINE ........................................................ 1
BENE-HMO-PRES ......................................................... 1
BENE-HOSPICE-INDICATOR ................................................ 2
BENE-SW ............................................................... 2
BLD-TO-BE-MET ......................................................... 2
BLOOD-SW .............................................................. 3
C-AETNA-TRANSITION .................................................... 4
CA-CAN-CRD-ICN ........................................................ 4
CA-EARL-BILL-DATE ..................................................... 5
CA-EXHAUS-DATE ........................................................ 5
CA-INLIER-EXHAUST-SW .................................................. 5
CA-PSYCH-AFTER-UTIL ................................................... 6
CA-PSY-PRE-ENT-SW ..................................................... 6
CA-SEC-SPELL-WK-CODE .................................................. 6
CA-SPELL-WK-CODE ...................................................... 6
CLAIM-AGE ............................................................. 6
CLAIM-IS-HOME-HEALTH .................................................. 7
CLAIM-IS-HOSPICE ...................................................... 7
CLAIM-IS-OSA .......................................................... 7
CLAIM-IS-OUTPATIENT ................................................... 7
CLM-BILL-TYPE-72-ESRD ................................................. 7
CLM-FRM-DATE .......................................................... 7
CLM-TRU-DATE .......................................................... 7
CLMN-TOT-EXP .......................................................... 8
CLM-TYPE-11-41 ........................................................ 8
CMN-AI-SKEL-HUBC ...................................................... 8
CMN-T-CERT-INIT ....................................................... 8
CMN-T-CERT-RECERT ..................................................... 8
COMP-NC ............................................................... 8
COMP-TOT .............................................................. 8
DENIED-CLAIM .......................................................... 9
DENIED-LI ............................................................. 9
DENIED-LINE-ITEM ...................................................... 9
DMEPOS-CLAIM .......................................................... 9
DMEPOS-ENTRY .......................................................... 9
DOWNCODE-SKEL-EXPIRED ................................................. 9
DUPE-SW ............................................................... 9
ERROR-STILL-VALID .................................................... 11
ESRD-CLAIM-PRESENT-SW ................................................ 11
FNOPAY-SW ............................................................ 11
GLOBAL-BILL-SW ....................................................... 13
GLOBAL-MAMMO-BILL .................................................... 13
HH-ADJ-SW ............................................................ 13
HIST-ADM-DTE-MINUS1 .................................................. 14
HIST-ADM-DTE-MINUS4 .................................................. 14
HIST-BILL-TYPE12-HOSPITAL ............................................ 14
HIST-BILL-TYPE-72-ESRD ............................................... 14
HISTORY-MATCH ........................................................ 14
HLD-BENE-EXP ......................................................... 17
HLD-BLD-DED (OUTPATIENT) ............................................. 17
HLD-BLD-DED (PART B/DME) ............................................. 19
ii
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
Detailed Table of Contents
________________________________________________________________________
HLD-BLD-TBM .......................................................... 20
HLD-DED-TBM (OUTPATIENT) ............................................. 21
HLD-DED-TBM (PART B/DME) ............................................. 21
HLD-MED-EXP (Outpatient claims) ...................................... 21
HLD-MED-EXP .......................................................... 22
HLD-OTHPY-EXP ........................................................ 23
HLD-PSY-EXP (Outpatient claims) ...................................... 23
HLD-PSY-EXP .......................................................... 23
HLD-PTHPY-EXP ........................................................ 24
HLD-RICR-PSY ......................................................... 24
HLD-RICR-OTHPY ....................................................... 24
HLD-RICR-PTHPY ....................................................... 25
HLD-TOT-EXP .......................................................... 25
HMO-PD-SW ............................................................ 25
HOSPICE MASTER TABLES ................................................ 27
HOSPICE-NOE-ADD-BILL ................................................. 27
HOSPICE-NOE-BILL ..................................................... 27
HSPM-START1-DATE ..................................................... 27
HSPM-TERM-DATE ....................................................... 27
HSPM-TERM-SWITCH ..................................................... 27
HUBC-DEMO-NUM-CABG-COE ............................................... 27
HUBC-NON-PHYS-SPEC-CODES ............................................. 28
HUBC-SLIDE-PREP-CODE ................................................. 28
HUIN-SNF-IND ......................................................... 28
IMMUNO DRUG TABLE .................................................... 29
MAMM-HIRISK .......................................................... 33
MAMM-LOWRISK ......................................................... 33
MAMMOGRAPHY-BILL ..................................................... 33
MAMMOGRAPHY-BILL-PRESENT ............................................. 34
MAMM-SPAN-DATE-PRESENT ............................................... 34
MAMM-SPAN-DATE-VALID ................................................. 34
MAX-CASH-DED-FOR-THIS-CLAIM .......................................... 34
MSP-MATCHED .......................................................... 34
NON-PPS-CLAIM ........................................................ 35
NOT-CLIA-WAIVER-CAT69-MODQW .......................................... 35
ONE-HUND-NOT-SUBJ .................................................... 35
ONE-HUND-SUBJ ........................................................ 36
OT ................................................................... 36
OUTPATIENT-TRANS-ID .................................................. 36
PARTB-ENTRY .......................................................... 36
PARTB-TRANS-ID ....................................................... 36
PATIENT-STATUS-IS-DOD-HOSPICE ........................................ 36
POSCAT-PEN-PUMP ...................................................... 36
PP-IND ............................................................... 36
PPS-TRANSITION-CLAIM-SW .............................................. 37
PPS-STATE-EFFECTIVE-TABLE ...................................... 39
PPS-PROV-EFFECTIVE-TABLE ....................................... 39
PRI-PAY-AMT (Outpatient claims) ...................................... 40
PRI-PAY-AMT .......................................................... 40
PROFESSIONAL-BILL-SW ................................................. 40
PROCESS-L1002-REPROCESS-PATH ......................................... 40
PSYC ................................................................. 40
PT ................................................................... 41
iii
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
Detailed Table of Contents
________________________________________________________________________
QUAL-BYPASS-SW ....................................................... 41
REIMB-SW ............................................................. 42
RETRIEVE-HISTORY ..................................................... 42
RHC-MAMMO-71X-BILL-SW ................................................ 42
S-CHOICES-BENE ....................................................... 43
S-CHOICES-HMO ........................................................ 43
S-CLAIM-CANCELLED .................................................... 43
S-CLAIM-FOUND ........................................................ 45
S-CONDITION-CODE-M1-PRESENT .......................................... 47
S-FIND-NON-PPS-BILL .................................................. 47
S-FLU-OR-PNEUMO-HCPC-PRESENT ......................................... 47
S-HMO-STATUS ......................................................... 47
SLOT-1ST-PROVIDER-CO ................................................. 50
SLOT-2ND-PROVIDER .................................................... 51
SLOT-2ND-PROVIDER-CO ................................................. 51
S-MAMMO-REV-HCPC-PRESENT ............................................. 51
S-NOT-FIND-NON-PPS-BILL .............................................. 52
S-NOT-FIND-NON-PPS-BILL .............................................. 52
SPECIAL-BIC-SEX ...................................................... 52
START1-CHANGED ....................................................... 52
START1-CO-CHANGED .................................................... 52
START2-CHANGED ....................................................... 53
START2-CO-CHANGED .................................................... 53
STATES-TO-BYPASS-CLIA ................................................ 54
SW-HOSPICE-STATUS .................................................... 54
TECHNICAL-BILL-SW .................................................... 55
TELEMEDICINE-PROJECT-HCPCS ........................................... 56
TOT-CHGS-HLD ......................................................... 56
TOTAL DATE PROCESS ................................................... 56
YR-CON Table ................................................... 56
UTILIZATION DAYS CALCULATIONS ........................................ 58
VALID-ADD-YR ......................................................... 60
VALID-CAT ............................................................ 60
VALID-CAT5 ........................................................... 61
VALID-CAT6 ........................................................... 61
VALID-DELV-CAT ....................................................... 61
VALID-LENGTH ......................................................... 61
VALID-MSP-CODE ....................................................... 61
VALID-PPUMP-RENT ..................................................... 61
VALID-SCRN-RSLT ...................................................... 61
W-BLOOD-HCPCS-CODE ................................................... 61
W-BLOOD-TYPE ......................................................... 62
WITHN-HMO ............................................................ 62
W-KIDNEY-DONOR ....................................................... 64
WK-PSY-DED ........................................................... 64
WORK-PSYCH-EXP-REMAIN ................................................ 64
WORK-RICR-PSYCH-REMAIN ............................................... 65
WS-AI-SKEL-HUBC ...................................................... 65
WS-BENE-PARTB-ENTITLED-SW ............................................ 65
WS-BENE-MAMM-DATE .................................................... 66
For Part B claims .............................................. 67
For Outpatient claims .......................................... 67
WS-BILL-TYPE-HOSPICE-NOE ............................................. 67
iv
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
Detailed Table of Contents
________________________________________________________________________
WS-BILL-TYPE-NOE-CHANGE-OWNER ........................................ 67
WS-BILL-TYPE-NOE-CHANGE-PROV ......................................... 67
WS-BILL-TYPE-NOE-REVOKE .............................................. 67
WS-CASH-DEDUCT-AMT ................................................... 68
WS-C-NON-CAT-59 ...................................................... 68
WS-C-SHOE-HCPCS-ANY .................................................. 69
WS-CHOICES-ID ........................................................ 69
WS-CLAIM-COMPARE-DATE ................................................ 69
WS-CLAIM-DATE-OF-SERVICE ............................................. 69
For Part B claims .............................................. 69
For Outpatient claims .......................................... 70
WS-CLAIM-MAMM-DATE ................................................... 70
WS-DATE-EFF-ERR ...................................................... 70
WS-ERROR-SW .......................................................... 71
WS-ESRD-MANAGE-CARE-ID ............................................... 71
WS-ESRD-NGDATA ....................................................... 71
WS-HOLD-FROM-DATE .................................................... 71
WS-HOLD-THRU-DATE .................................................... 72
WS-HO-PROCESS-SW ..................................................... 72
WS-INIT-ERR-IND ...................................................... 74
WS-IX ................................................................ 74
WS-ERR-IND ........................................................... 74
WS-MAMMOGRAPHY-CLAIM-SW .............................................. 74
WS-MOD1-Q3 ........................................................... 75
WS-MOD2-Q3 ........................................................... 75
WS-MSP-AMT-APPLIED ................................................... 75
WS-MSP-TYPE-CODE ..................................................... 75
WS-NDX-AI ............................................................ 79
WS-NDX-AR ............................................................ 79
WS-NULL-IND .......................................................... 79
WS-PRE-ENT-PERIOD-SW ................................................. 80
WS-REL-CERT-TRM-DATE ................................................. 80
WS-STATE-TABLE-VALUES ................................................ 80
WS-TOTAL-PSY-DAYS .................................................... 81
WSV-CERT-END ......................................................... 82
WS-VER-CSH-DED ....................................................... 82
WS-YES-AI-OCC ........................................................ 83
YEAR-MATCH-SW ........................................................ 83
1
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
ADJUST ROUTINE
______________
Move the date fields passed to the routine (WS-CMM, WS-CDD, WS-
CYY) to the work areas used by this routine (WS-RM, WS-RD, WS-RY).
The WS-RM work area is computed by adding the value in WS-ADJUST-
AMT to an amount that was moved to this work area before this
routine was called.
The following logic is performed to insure that the date returned
by this routine is a valid date:
- The WS-REX-YR work area is computed by dividing the WS-RM
work area by '12'; the remainder is placed in WS-RM.
- When WS-RM is equal to '0', '12' is moved to WS-RM, '1' is
subtracted from WS-REX-YR, and WS-REX-YR is added to WS-RY.
- When WS-RY is greater than, or equal to, '100', '100' is
subtracted from WS-RY.
- When WS-RM is equal to '2', WS-RY is equal to '84', '88',
'92', '96', '0', '4', '8', or '12', and WS-RD is greater
than '29', '29' is moved to WS-RD. When WS-RY is not one of
these leap years, and WS-RD is greater than '28', '28' is
moved to WS-RD.
- When WS-RM is equal to '4', '6', '9', or '11', and WS-RD is
greater than '30', '30' is moved to WS-RD.
- Overlay the work areas passed to this routine with the work
areas calculated during this routine.
- When the year is less than '61', move '20' to WS-CC2.
Otherwise, move '19' to WS-CC2.
BENE-HMO-PRES
_____________
This '88' level is true when the Group Health Organization
Auxiliary indicator (BENE-HMO-IND) is equal to '1'.
2
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
BENE-HOSPICE-INDICATOR
______________________
This indicator is on the Beneficiary Master file. If the
indicator is equal to '0', there is no Hospice data. If the
indicator is equal to '1', there is data available on the
Auxiliary file.
BENE-SW
_______
This field is calculated as follows:
BENE-SW is set as follows:
- Prior to processing the Beneficiary Part B trailer table
using the YEAR-SUB index, set BENE-SW to 'N'.
- When the claim from year is equal to the Part B year (YEAR-
SUB) on the trailer table, set BENE-SW to 'Y'.
- When the BENE-SW is not equal to 'Y' after done processing
the Beneficiary Part B trailer table using the YEAR-SUB
index, set BENE-SW to 'N'.
BLD-TO-BE-MET
_____________
This field is calculated as follows:
BLD-SUB is a table index for the Beneficiary Blood Deductible
Table, varied from '1' to '5'.
- When the Beneficiary Remaining Part A/B Blood Deductible
Pints (BLD-SUB) is less than '4', calculate BLD-TO-BE-MET is
equal to '3' minus the Beneficiary Remaining Part A/B Blood
Deductible Pints (BLD-SUB).
- When the Beneficiary Remaining Part A/B Blood Deductible
Pints (BLD-SUB) is not less than '4', move zero to BLD-TO-
BE-MET.
3
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
BLOOD-SW
________
This field is calculated as follows:
NOTE: WS-BLD-FURN is set to the value amount of Value Code '37' on
the claim, or set to zero if this Value Code does not exist
on the claim.
WS-BLD-DED is set to the value amount of Value Code '38' on
the claim, or set to zero if this Value Code does not exist
on the claim.
WS-BLD-REPL is set to the value amount of Value Code '39' on
the claim, or set to zero if this Value Code does not exist
on the claim.
WS-BLD-REVENUE-PINTS is calculated as the sum of the
financial, or revenue, units of service for claim Revenue
Codes greater than '0379', and less than '0390'.
- Initialize BLOOD-SW to '0' prior to any blood deductible
processing.
- When the claim From Date is greater than '88366', the claim
from year is not less than the Beneficiary Part B fifth
year, WS-BLD-DED plus WS-BLD-REPL is greater than '0', the
Beneficiary Remaining Part A/B Blood Deductible Year is a
valid year, the claim from year is equal to the Beneficiary
Remaining Part A/B Blood Deductible Year, and BLD-TO-BE-MET
is less than WS-BLD-DED, set BLOOD-SW to '0'.
- When the claim From Date is greater than '88366', the claim
from year is not less than the Beneficiary Part B fifth
year, WS-BLD-DED plus WS-BLD-REPL is greater than '0', the
Beneficiary Remaining Part A/B Blood Deductible Year is a
valid year, the claim from year is equal to the Beneficiary
Remaining Part A/B Blood Deductible Year, BLD-TO-BE-MET is
not less than WS-BLD-DED, WS-BLD-FURN is equal to BLD-TO-BE-
MET, and BLD-TO-BE-MET is greater than WS-BLD-DED plus WS-
BLD-REPL, move 'U' to BLOOD-SW.
- When the claim From Date is greater than '88366', the claim
from year is not less than the Beneficiary Part B fifth
year, WS-BLD-DED plus WS-BLD-REPL is greater than '0', the
Beneficiary Remaining Part A/B Blood Deductible Year is a
valid year, the claim from year is equal to the Beneficiary
Remaining Part A/B Blood Deductible Year, BLD-TO-BE-MET is
not less than WS-BLD-DED, WS-BLD-FURN is less than BLD-TO-
BE-MET, and WS-BLD-DED plus WS-BLD-REPL is less than WS-BLD-
FURN, move 'U' to BLOOD-SW.
- When the claim From Date is greater than '88366', the claim
from year is not less than the Beneficiary Part B fifth
year, WS-BLD-DED plus WS-BLD-REPL is greater than '0', the
4
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
Beneficiary Remaining Part A/B Blood Deductible Year is a
valid year, the claim from year is equal to the Beneficiary
Remaining Part A/B Blood Deductible Year, BLD-TO-BE-MET is
not less than WS-BLD-DED, WS-BLD-FURN is less than BLD-TO-
BE-MET, and WS-BLD-DED plus WS-BLD-REPL is greater than WS-
BLD-FURN, move 'O' to BLOOD-SW.
- When the claim From Date is greater than '88366', the claim
from year is not less than the Beneficiary Part B fifth
year, WS-BLD-DED plus WS-BLD-REPL is greater than zero, the
Beneficiary Remaining Part A/B Blood Deductible Year is a
valid year, and the claim from year is equal to the
Beneficiary Remaining Part A/B Blood Deductible Year, and
BLD-TO-BE-MET is not less than WS-BLD-DED, WS-BLD-FURN is
greater than BLD-TO-BE-MET, and BLD-TO-BE-MET is greater
than WS-BLD-DED plus WS-BLD-REPL, move 'U' to BLOOD-SW.
- When HLD-BLD-DED is not less than '3.0', and WS-BLD-DED is
not equal to zero, move 'O' to BLOOD-SW.
- When HLD-BLD-DED is less than '3.0', and WS-BLD-DED plus
HLD-BLD-DED is greater than '3.0', move 'O' to BLOOD-SW.
- When HLD-BLD-DED is less than '3.0', WS-BLD-DED plus HLD-
BLD-DED is less than '3.0', WS-BLD-DED is not equal to WS-
BLD-FURN, WS-BLD-DED plus WS-BLD-REPL plus HLD-BLD-DED is
greater than '3.0', and WS-BLD-FURN minus WS-BLD-REPL is not
equal to '0', and not equal to WS-BLD-REVENUE-PINTS, move
'U' to BLOOD-SW.
- When WS-BLD-DED plus WS-BLD-REPL is not greater than '3.0',
WS-BLD-FURN is greater than '0', WS-BLD-DED plus WS-BLD-REPL
is equal to '0', and HLD-BLD-DED is less than '3.0', move
'U' to BLOOD-SW.
C-AETNA-TRANSITION
__________________
This '88' level is true when the intermediary number on the claim
is equal to one of the following values:
'00010', '00020', '00030', '00040', '00060', '00070', '00090',
'00101', '00130', '00140', '00160', '00180', '00190', '00220',
'00230', '00270', '00280', '00308', '00310', '00332', '00340',
'00350', '00362', '00363', '00380', '00390', '00400', '00423',
'00430', '00450', '00460', '17120', '52280'.
CA-CAN-CRD-ICN
______________
When the Action Code is equal to '5', set CA-CAN-CRD-ICN to the
original Fiscal Intermediary Claim Control Number entered on the
adjustment that represents the claim on history that is to be
adjusted.
5
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
When the Action Code is not equal to '5', set CA-CAN-CRD-ICN to
the Fiscal Intermediary Claim Control Number of the adjustment
that is processing.
CA-EARL-BILL-DATE
_________________
Initially, set CA-EARL-BILL-DATE to the Admission Date.
When CA-EARL-BILL-DATE is less than the Beneficiary Part A
entitlement Start Date, set CA-EARL-BILL-DATE to the Beneficiary
Part A entitlement Start Date.
CA-EXHAUS-DATE
______________
All Occurrence Codes are scanned sequentially.
The CA-EXHAUS-DATE is set to '0'.
When the Occurrence Code is equal to '00', setting the CA-EXHAUS-
DATE is bypassed.
When the Occurrence Code equals 'A3', and the Occurrence Date is
greater than '88366' and less than '90001', set the CA-EXHAUS-DATE
to the Occurrence Date.
CA-INLIER-EXHAUST-SW
____________________
CA-INLIER-EXHAUST-SW IS SET AS FOLLOWS:
- When Occurrence Code 'A3' and Condition Code '60' or '61'
are present on a non-SNF bill, the From Date is less than
01/01/1989, the Thru Date is greater than 12/31/1989, and
the total Lifetime Reserve Days are greater than '0' and
less than the utilized days, set CA-INLIER-EXAUST-SW to 'Y'.
- When there is an Occurrence Code of 'A3' on the bill, and
the bill is not a SNF bill, set CA-INLIER-EXAUST-SW to 'Y'.
- When a Span Code '70' is present on the bill, and there is
no overlap to a catastrophic period (the bill From Date is
not less than 1989 with a bill Thru Date greater than 1989,
and the bill From Date is not less than 1990 with a bill
Thru Date greater than 1990), the Occurrence Code Dates are
prior to the Stay From Date on the bill, but equal to, or
greater than, the bill Admission Date, and when the total
Lifetime Reserve Days are greater than '0' and equal to the
utilized days, and a Condition Code '60' or '61' is present
on the bill, set the CA-INLIER-EXHAUST-SW to 'Y'.
6
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
CA-PSYCH-AFTER-UTIL
___________________
CA-PSYCH-AFTER-UTIL equals the Outpatient pre-entitlement
psychiatric days minus WS-TOTAL-PSY-DAYS.
CA-PSY-PRE-ENT-SW
_________________
When the third position of the Provider Number equals 'S' or '4',
the Beneficiary psychiatric hospital Discharge Date is greater
than '0' and is not less than the Beneficiary Part A entitlement
Start Date, the Beneficiary Part A entitlement Start Date is
greater than '89000' and less than '90000', and the Admission Date
is less than the Beneficiary psychiatric hospital Discharge Date,
set the CA-PSY-PRE-ENT-SW switch to 'Y'.
When the Admission Date is less than the Beneficiary Part A
entitlement Start Date, or the pre-entitlement psychiatric days
are greater than '0', or WS-PRE-ENT-PERIOD-SW is equal to 'Y', set
the CA-PSY-PRE-ENT-SW switch to 'Y'.
CA-SEC-SPELL-WK-CODE
____________________
This field (which is currently being worked with) identifies the
second spell. Two spells may be worked with at a time for
comparison purposes. Zero indicates that there is no spell.
CA-SPELL-WK-CODE
________________
This field (which is currently being worked with) identifies the
spell. Zero indicates that there is no spell.
CLAIM-AGE
_________
The CLAIM-AGE represents the Beneficiary's age at the time of the
expense. This age is calculated as follows:
- WS-CLAIM-DATE-OF-SERVICE is moved to CLAIM-HLD9.
- The Beneficiary date of birth is moved to DOB-HLD9.
- Subtract the DOB-HLD9 from the CLAIM-HLD9 and place
those results in AGE-DIFF9.
- Adjust AGE-DIFF9 for a leap year.
7
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- Add AGE1234 to CLAIM-AGE.
CLAIM-IS-HOME-HEALTH
____________________
This '88' level is true when the Claim Type is equal to 'HUHH',
'HIHH', or 'HBHH'.
CLAIM-IS-HOSPICE
________________
This '88' level is true when the Claim Type is equal to 'HUHC',
'HIHC', or 'HBHC'.
CLAIM-IS-OSA
____________
This '88' level is true when positions' 1' and '2' of the Claim
Type are equal to 'HB'.
CLAIM-IS-OUTPATIENT
___________________
This '88' level is true when the Claim Type is equal to 'HUOP',
'HIOP', or 'HBOP'.
CLM-BILL-TYPE-72-ESRD
_____________________
CLM-BILL-TYPE-72-ESRD is set to true when the incoming Outpatient
claim bill type is equal to '72x'.
CLM-FRM-DATE
____________
This field is used to reference the incoming claim Service From
Date, or if the claim is Outpatient, and there is a Span Code '72'
present, the Span Code '72' From Date.
CLM-TRU-DATE
____________
This field is used to reference the incoming claim service Thru
Date, or if the claim is Outpatient and there is a Span Code '72'
present, the Span Code '72' Thru Date.
8
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
CLMN-TOT-EXP
____________
CLMN-TOT-EXP is equal to the sum of the claim Part B total charge,
subject to deductible, plus the claim Part B total physical
therapy charges, subject to deductible, plus the claim Part B
total occupational therapy charges, subject to deductible, plus
the accumulation of '.625' times the allowable charges per line
item on the claim, where the CMS service type is equal to 'T'.
CLM-TYPE-11-41
______________
CLM-TYPE-11-41 is true when the incoming bill types are '11x' and
'41x'.
CMN-AI-SKEL-HUBC
________________
CMN-AI-SKEL-HUBC is set to true when the CMN Auxiliary file is
read, and the CMN skeleton indicator is 'Y'.
CMN-T-CERT-INIT
_______________
This '88' level is true when the CMN certification type is equal
to '1'.
CMN-T-CERT-RECERT
_________________
This '88' level is true when the CMN certification type equals
'3'.
COMP-NC
_______
This field is accumulated for each Revenue Center Code on the
claim. It is calculated as follows:
When the Revenue Center Code is not equal to '0001', and the
financial, or Revenue Override Code is not equal to '0004', the
Inpatient financial non-covered charges are added to COMP-NC.
COMP-TOT
________
This field is accumulated for each Revenue Center Code on the
claim. It is calculated as follows:
9
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
When the Revenue Center Code is not equal to '0001', and the
financial, or Revenue Override Code is not equal to '4', the
Inpatient financial charges are added to COMP-TOT.
DENIED-CLAIM
____________
This '88' level is true when the claim Payment Denial Indicator is
equal to 'D', 'O', 'Q', 'T', 'U', 'V', 'X', or 'Y'.
DENIED-LI
_________
This '88' level is true when the CMS-PAY-PROCESS-IND is equal to
'B', 'C', 'M', 'N', 'I', 'L', 'O', 'P', 'Q', 'T', 'U', 'V', 'X',
or 'Y'.
DENIED-LINE-ITEM
________________
DENIED-LINE-ITEM is a representation of the claim Line Item
Payment Process Indicator when it is equal to 'B', 'C', 'I', 'L',
'M', 'N', 'O', 'P', 'Q', 'T', 'U', 'V', 'X', or 'Y'.
DMEPOS-CLAIM
____________
DMEPOS-CLAIM is a representation of the Transaction ID when it is
equal to 'HBDC', 'HUDC', or 'HIDC'.
DMEPOS-ENTRY
____________
This '88' level is true when the HUBC-REC-ID is equal to 'HUDC' or
'HIDC'.
DOWNCODE-SKEL-EXPIRED
_____________________
This '88' level is true when the Certificate of Medical Necessity
initial certification is less than '1' for down-coded HCPCS.
DUPE-SW
_______
This switch is used while interrogating Outpatient history.
- Set DUPE-SW to 'N' initially.
10
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the incoming claim Transaction Identifier is equal to
'HBOP', the incoming claim cable indicator is equal to 'B',
and the history claim Source of Bill Indicator is equal to
'2', check the next Outpatient history record.
- When the history claim Action Code is equal to '4' or '6',
and the history Record Type is equal to '6', check the next
Outpatient history record.
- When the Outpatient history service From Date is equal to
the service From Date on the claim, the Outpatient history
service Thru Date is equal to the service Thru Date on the
claim, the history and claim Intermediary Control Numbers
are equal, the history and Provider Numbers are equal, and
the Outpatient history Cancel Date is equal to zeros, set
DUPE-SW to 'D'.
- When CLAIM-IS-HOSPICE, and the Outpatient history service
From Date is equal to the service From Date on the claim,
the Outpatient history service Thru Date is equal to the
service Thru Date on the claim, the bill type on both the
Outpatient history and claim records is equal to '815' or
'825', the Action Code on the claim is equal to '1', and the
Outpatient history Cancel Date is equal to zeros, set DUPE-
SW to 'D'.
- When CLAIM-IS-HOSPICE, and the Outpatient history service
From Date is equal to the service From Date on the claim,
the Outpatient history service Thru Date is equal to the
service Thru Date on the claim, and the Outpatient history
Cancel Date is equal to zeros, set DUPE-SW to 'D'.
When CLAIM-IS-HOSPICE, and when the history claim
dates do not equal the incoming claim dates, when the
first two positions of the history bill type are equal
to '81' or '82' and the incoming claim bill type is
equal to '815' or '825',
OR
- The history claim dates do not equal the incoming claim
dates, when
- The incoming service From Date is greater than or equal to
the history service From Date and is less than the history
service Thru Date,
OR
- The incoming service Thru Date is greater than the history
service From Date and is less than or equal to the history
service Thru Date,
OR
11
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- The incoming service From Date is less than or equal to the
history service From Date and the incoming service Thru Date
is greater than, or equal to, the history service Thru Date,
OR
- The incoming service From Date is greater than or equal to
the history service From Date and the incoming service Thru
Date is less than or equal to the history service Thru Date,
OR
- The incoming service From Date is less than or equal to the
history service From Date and the incoming service Thru Date
is less than or equal to the history service Thru Date,
AND
- The history Cancel Date is equal to zero,
Set DUPE-SW to 'O'.
ERROR-STILL-VALID
_________________
ERROR-STILL-VALID is set to true and stays true unless:
When WS-AI-UPDATED-FROM-PCH is not 'U', and the WS-AI-CREAT-DATE
is less than C-JULY-3-1995, WS-AI-PCH-DCSN is not equal to 'P',
and the allowed amount is less than, or equal to, the DME allowed
amount.
ESRD-CLAIM-PRESENT-SW
_____________________
ESRD-CLAIM-PRESENT is an '88' level that is considered true when
ESRD-CLAIM-PRESENT-SW is equal to 'Y'.
ESRD-CLAIM-PRESENT-SW switch is set to 'Y' as follows:
Each line item on the claim that does not have a Payment Process
Indicator of 'B', 'C, 'M', 'N', 'I', 'O', 'X', 'Y', 'V', 'L', 'P',
'T', or 'U', does have a claim From Date greater than '90031' and
a CMS service type of 'L', is examined for the HCPCS edit category
codes.
When a claim has a line item with a HCPCS edit Category Code of
'008', and not '061', a 'Y' is moved to ESRD-CLAIM-PRESENT-SW to
signify ESRD-CLAIM-PRESENT.
FNOPAY-SW
12
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
_________
The following conditions will set the FNOPAY-SW to 'Y':
1) When the Revenue Code is equal to '0001'
AND
When the financial or revenue charges are numeric and the
financial or revenue non-covered charges are numeric
AND
When the financial or revenue charges are equal to the
financial or revenue non-covered charges,
AND
When the patient status is not equal to '30'
AND
When the Inpatient non-payment code is equal to 'B', 'C', or
'N'
AND
When the Inpatient utilization days are equal to zeros or
spaces
2) When the Revenue Code is equal to '0001'
AND
When the financial or revenue charges are numeric
AND
When the financial or revenue charges are equal to zeros and
the financial or revenue non-covered charges are equal to
spaces
AND
When the patient status is not equal to '30'
AND
When the Inpatient non-payment code is equal to 'B', 'C', or
'N'
AND
When the Inpatient utilization days are equal to zeros or
spaces
13
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
GLOBAL-BILL-SW
______________
For Outpatient claims, this switch is always set to 'N'.
For Part-B claims:
When the Procedure Code Modifier '1' or '2' is not equal to 'TC'
or '26', move 'Y' to this switch.
GLOBAL-MAMMO-BILL
_________________
This '88' level is true when the first two positions of the bill
type are equal to '14', '22', '23', or '85', or RHC-MAMMO-71X-
BILL, and the Revenue Code is equal to '0403'.
When the first two positions of the bill type are equal to '14',
'22', '23', or '85', or RHC-MAMMO-71X-BILL, the Revenue Code is
not equal to '0403', and the HCPCS code is equal to '76092', set
WS-GLOBAL-MAMMO-SW to 'Y' (GLOBAL-MAMMO-BILL becomes true)
HH-ADJ-SW
_________
This field is calculated as follows:
HH-ADJ-SW is set as follows:
- When not CLAIM-IS-OUTPATIENT, and no errors occurred while
validating Beneficiary Part A entitlement, and the claim
Record Identification Code is equal to 'W' (Part B bill),
set HH-ADJ-SW to 'Y'.
- When the claim Record Identification Code is equal to 'V'
(Part A bill), and one of the following is true:
- When not CLAIM-IS-HOSPICE and no errors occurred while
validating Beneficiary Part B entitlement
OR
- When CLAIM-IS-HOSPICE and no errors occurred while
validating Beneficiary Part A entitlement,
set HH-ADJ-SW to 'Y'.
14
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
HIST-ADM-DTE-MINUS1
___________________
This field is calculated by subtracting '1' from the Inpatient
Admission Date. This field, like the Inpatient Admission Date, is
stored in Julian format.
HIST-ADM-DTE-MINUS4
___________________
This field is calculated by subtracting '4' from the Inpatient
Admission Date. This field, like the Inpatient Admission Date, is
stored in Julian format.
HIST-BILL-TYPE12-HOSPITAL
_________________________
HIST-BILL-TYPE12-HOSPITAL is true when the Inpatient history bill
type is equal to '11x' and '41x'.
HIST-BILL-TYPE-72-ESRD
______________________
HIST-BILL-TYPE-72-ESRD is true when the history Outpatient claim
bill type is equal to '72x'.
HISTORY-MATCH
_____________
This '88' level is set as follows:
NOTE: SUB-HST is an index for the Hospice history pointer table.
It is set to '1' initially and incremented by '1' after each
table entry is processed until it is greater than the number
of pointers present on the table, or HISTORY-MATCH, or an
I/O error occurs on the read to the Hospice history file.
NOTE: SUB-CHG is a table index for the Old Hospice Master Table.
It is set to the table entry for the changed Hospice period.
- When START1-CO-CHANGED, and the claim From Date is not
equal to the first Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
SUB-HST is not marked for deletion, the claim From
Date is equal to the first Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the read to the Hospice history file is
successful, and the history Cancel Date is equal to
zero, set HISTORY-MATCH to true.
15
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When START2-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Start Date (SUB-
CHG) on the old Hospice Table, the Hospice history
table entry pointed to by SUB-HST is not marked for
deletion, the claim From Date is equal to the second
Hospice Provider Start Date (SUB-CHG) on the old
Hospice Table, the read to the Hospice history file is
successful, and the history Cancel Date is equal to
zero, set HISTORY-MATCH to true.
- When START2-CO-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
SUB-HST is not marked for deletion, the claim From
Date is equal to the second Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the read to the Hospice history file is
successful, and the history Cancel Date is equal to
zero, set HISTORY-MATCH to true.
- When START1-CO-CHANGED, and the claim From Date is not
equal to the first Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
SUB-HST is not marked for deletion, the claim From
Date is greater than the first Hospice Provider Change
of Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history From Date (SUB-HST) is less
than the claim From Date, the Hospice history Thru
Date (SUB-HST) is greater than, or equal to, the first
Hospice Provider Change of Ownership Start Date (SUB-
CHG) on the old Hospice Table, the read to the Hospice
history file is successful, and the history Cancel
Date is equal to zero, set HISTORY-MATCH to true.
- When START2-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Start Date (SUB
-CHG) on the old Hospice Table, the Hospice history
table entry pointed to by SUB-HST is not marked for
deletion, the claim From Date is greater than the
second Hospice Provider Start Date (SUB-CHG) on the
old Hospice Table, the Hospice history From Date
(SUB-HST) is less than the claim From Date, the
Hospice history Thru Date (SUB-HST) is greater than,
or equal to, the second Hospice Provider Start Date
(SUB-CHG) on the old Hospice Table, the read to the
Hospice history file is successful, and the history
Cancel Date is equal to zero, set HISTORY-MATCH to
true.
- When START2-CO-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
16
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
SUB-HST is not marked for deletion, the claim From
Date is greater than the second Hospice Provider
Change of Ownership Start Date (SUB-CHG) on the old
Hospice Table, the Hospice history From Date (SUB-HST)
is less than the claim From Date, the Hospice history
Thru Date (SUB-HST) is greater than or equal to the
second Hospice Provider Change of Ownership Start Date
(SUB-CHG) on the old Hospice Table, the read to the
Hospice history file is successful, and the history
Cancel Date is equal to zero, set HISTORY-MATCH to
true.
- When START1-CO-CHANGED, and the claim From Date is not
equal to the first Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
SUB-HST is not marked for deletion, the claim From
Date is less than the first Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history From Date (SUB-HST) is less
than the first Hospice Provider Change of Ownership
Start Date (SUB-CHG) on the old Hospice Table, the
Hospice history Thru Date (SUB-HST) is greater than or
equal to the claim From Date, the read to the Hospice
history file is successful, and the history Cancel
Date is equal to zero, set HISTORY-MATCH to true.
- When START2-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Start Date (SUB-
CHG) on the old Hospice Table, the Hospice history
table entry pointed to by SUB-HST is not marked for
deletion, the claim From Date is less than the second
Hospice Provider Start Date (SUB-CHG) on the old
Hospice Table, the Hospice history From Date (SUB-HST)
is less than the second Hospice Provider Start Date
(SUB-CHG) on the old Hospice Table, the Hospice
history Thru Date (SUB-HST) is greater than, or equal
to, the claim From Date, the read to the Hospice
history file is successful, and the history Cancel
Date is equal to zero, set HISTORY-MATCH to true.
- When START2-CO-CHANGED, and the claim From Date is not
equal to the second Hospice Provider Change of
Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history table entry pointed to by
SUB-HST is not marked for deletion, the claim From
Date is less than the second Hospice Provider Change
of Ownership Start Date (SUB-CHG) on the old Hospice
Table, the Hospice history From Date (SUB-HST) is less
than the second Hospice Provider Change of Ownership
Start Date (SUB-CHG) on the old Hospice Table, the
Hospice history Thru Date (SUB-HST) is greater than,
or equal to, the claim From Date, the read to the
Hospice history file is successful, and the history
Cancel Date is equal to zero, set HISTORY-MATCH to
17
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
true.
HLD-BENE-EXP
____________
This field is calculated as follows:
- When the claim stay From Date is greater than '88366', move
HLD-MED-EXP to HLD-BENE-EXP.
- When the claim stay From Date is not greater than '88366',
HLD-BENE-EXP is calculated by multiplying HLD-PSY-EXP by
'.625' and adding that result to HLD-MED-EXP.
HLD-BLD-DED (OUTPATIENT)
________________________
This field is set as follows:
- YEAR-SUB is a table index for the Beneficiary Part B trailer
table, varied from '1' to the number of entries in the
table.
- TRLR-SUB is a table index for the Beneficiary Part B trailer
table. It is set as follows:
- When the claim from year matches a Part B year on the
trailer table, TRLR-SUB points to the table entry in
which the match was found.
- When a Part B year on the trailer table is equal to
the default value, TRLR-SUB points to this table
entry.
- When neither of the above is true, TRLR-SUB is equal
to the number of entries in the Part B trailer table
plus '1'.
- TRLR-SUB1 is a table index for the Beneficiary Part B
trailer table, equal to TRLR-SUB minus '1'.
- BLD-SUB is a table index used to search the Beneficiary
Blood Deductible table.
- When BLD-SUB is greater than '5', or BLDYR-MATCH is true,
stop processing the table.
- BLDYR-MATCH is an '88' level, set as follows:
When the claim from year is equal to the Beneficiary
Remaining Part A/B Blood Deductible Year (BLD-SUB) on
the Beneficiary Blood Deductible Table, set BLDYR-
MATCH to true.
18
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
NOTE: WS-BLD-FURN is set to the value amount of Value Code '37' on
the claim, or set to zero if this Value Code does not exist
on the claim.
WS-BLD-DED is set to the value amount of Value Code '38' on
the claim, or set to zero if this Value Code does not exist
on the claim.
WS-BLD-REPL is set to the value amount of Value Code '39' on
the claim, or set to zero if this Value Code does not exist
on the claim.
- When WS-CASH-DEDUCT-AMT is not greater than zero, the claim
Action Code is equal to '7', the claim from year is either
less than the Beneficiary Part B year (TRLR-SUB1), or less
than the Beneficiary Part B fifth year, move '3' to HLD-BLD-
DED
- When the claim from year is equal to the Beneficiary Part B
year (YEAR-SUB), and the claim From Date is less than
'89001', move the Beneficiary Part B Blood Pint Quantity
Remaining (YEAR-SUB) on the blood deductible table to HLD-
BLD-DED.
- When the claim from year is equal to the Beneficiary Part B
year (YEAR-SUB), and BLDYR-MATCH and the table index, BLD-
SUB, is greater than one, move the Beneficiary Remaining
Part A/B Blood Deductible Pints (BLD-SUB-1) on the blood
deductible table to HLD-BLD-DED.
- When the claim from year is equal to the Beneficiary Part B
year (YEAR-SUB), and BLDYR-MATCH and the table index, BLD-
SUB, is less than or equal to one, move the Beneficiary
Remaining Part A/B Blood Deductible Pints (BLD-SUB) on the
blood deductible table to HLD-BLD-DED.
- When the claim from year is equal to the Beneficiary Part B
year (YEAR-SUB), and not BLDYR-MATCH, set HLD-BLD-DED to
zero.
- When processing an Outpatient claim adjustment, and either
not CLAIM-IS-HOSPICE, or not WS-BILL-TYPE-HOSPICE-NOE, and
BENE-SW is equal to 'N', set HLD-BLD-DED to zero.
- When WS-CASH-DEDUCT-AMT is greater than zero, the claim from
year does not match a Part B year on the trailer table, and
the claim from year is less than the Beneficiary Part B
fifth year, set HLD-BLD-DED to '3'.
- When WS-CASH-DEDUCT-AMT is greater than zero, the claim from
year does not match a Part B year on the trailer table, the
claim from year is not less than the Beneficiary Part B
fifth year, the claim Action Code is equal to '7', and the
Beneficiary Part B fifth year is the default value, the
19
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
claim from year is not less than the Beneficiary Part B year
(TRLR-SUB1) on the trailer table, and the Beneficiary Part B
year (1) is not equal to the default value, set HLD-BLD-DED
to '3'.
- When BENE-SW is equal to 'P', set HLD-BLD-DED to '3'.
- When not CLAIM-IS-HOME-HEALTH and one of the following is
true:
- When the claim From Date is not greater than '88366',
OR
- When the claim From Date is greater than '88366' and
BLOOD-SW is equal to '0', add '+0.5' to HLD-BLD-DED.
- When WS-BLD-DED plus WS-BLD-REPL is greater than
'3.0', add '+3.0' to HLD-BLD-DED.
- When WS-BLD-DED plus WS-BLD-REPL is not greater than
'3.0', WS-BLD-FURN is greater than zero, WS-BLD-DED
plus WS-BLD-REPL is equal to zero, and HLD-BLD-DED is
not less than '3', add the result of WS-BLD-DED plus
WS-BLD-REPL to HLD-BLD-DED.
- When WS-BLD-DED plus WS-BLD-REPL is not greater than
'3.0', WS-BLD-FURN is greater than zero, and WS-BLD-
DED plus WS-BLD-REPL is not equal to zero, add the
result of WS-BLD-DED plus WS-BLD-REPL to HLD-BLD-DED.
- When WS-BLD-DED plus WS-BLD-REPL is not greater than
'3.0', WS-BLD-FURN is not greater than zero, add the
result of WS-BLD-DED plus WS-BLD-REPL to HLD-BLD-DED.
- When processing an Outpatient claim adjustment, CLAIM-
IS-OUTPATIENT, the claim From Date is not greater than
'88366', the Outpatient history blood deductible plus
the Outpatient blood pints replaced is greater than
zero, subtract the result of the Outpatient history
blood deductible plus the Outpatient blood pints
replaced from HLD-BLD-DED.
- When processing an Outpatient claim adjustment, and
CLAIM-IS-OUTPATIENT, the claim From Date is not
greater than '88366', BLDYR-MATCH is true, the
Outpatient history blood deductible plus the
Outpatient blood pints replaced is greater than zero,
subtract the result of the Outpatient history blood
deductible plus the Outpatient blood pints replaced
from HLD-BLD-DED.
HLD-BLD-DED (PART B/DME)
________________________
20
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
HLD-BLD-DED is set as follows:
- When the claim first-expense year is less than the current
year minus '4', move '3' to HLD-BLD-DED.
- When the claim first-expense year equals the Beneficiary
Part B year, the claim first-expense date is less than
'89001', move the Beneficiary Part B blood pint quantity
remaining to HLD-BLD-DED.
- When the claim first-expense year equals the Beneficiary
Part B year, the claim first-expense date is greater than,
or equal to, '89001', search the blood trailer table on the
Beneficiary Master Record for a match between the claim
first-expense year and the Beneficiary Remaining Part A/B
Blood Deductible Year. When a match is found, move the
Beneficiary remaining Part A/B blood deductible pints to
HLD-BLD-DED.
- When the claim first-expense year equals the Beneficiary
Part B year, and the claim first-expense date is greater
than, or equal to, '89001', search the blood trailer table
on the Beneficiary Master Record for a match between the
claim first-expense year and the Beneficiary Remaining Part
A/B Blood Deductible Year. When a match is not found, move
zeros to HLD-BLD-DED.
- When the claim first-expense date is less than '89001',
initialize the HLD-BLD-DED to zeros.
- When the claim first-expense date is greater than, or equal
to, '89001', search the blood trailer table on the
Beneficiary Master Record for a match between the claim
first-expense year and the Beneficiary Remaining Part A/B
Blood Deductible Year. When a match is found, move the
Beneficiary remaining Part A/B blood deductible pints to
HLD-BLD-DED.
- When the claim first-expense date is greater than, or equal
to, '89001', search the blood trailer table on the
Beneficiary Master Record for a match between the claim
first-expense year and the Beneficiary Remaining Part A/B
Blood Deductible Year. When a match is not found,
initialize the HLD-BLD-DED to zeros.
HLD-BLD-TBM
___________
HLD-BLD-TBM is set as follows:
- When HLD-BLD-DED is greater than '3.0', move '0' to HLD-BLD-
TBM.
21
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When HLD-BLD-DED is less than or equal to '3.0', calculate
HLD-BLD-TBM by subtracting HLD-BLD-DED from '3.0'.
HLD-DED-TBM (OUTPATIENT)
________________________
This field is calculated as follows:
- When HLD-BENE-EXP is greater than MAX-CASH-DEDUCTIBLE-FOR-
THIS-CLAIM, set HLD-DED-TBM to zero.
- When HLD-BENE-EXP is not greater than MAX-CASH-DEDUCTIBLE-
FOR-THIS-CLAIM, and HLD-BENE-EXP is equal to zero, move MAX-
CASH-DEDUCTIBLE-FOR-THIS-CLAIM to HLD-DED-TBM.
- When HLD-BENE-EXP is not greater than MAX-CASH-DEDUCTIBLE-
FOR-THIS-CLAIM, and HLD-BENE-EXP is not equal to zero, HLD-
DED-TBM is calculated by subtracting HLD-BENE-EXP from MAX-
CASH-DEDUCTIBLE-FOR-THIS-CLAIM.
- When BENE-SW is equal to 'P', move zeroes to HLD-DED-TBM.
HLD-DED-TBM (PART B/DME)
________________________
HLD-DED-TBM is calculated as follows:
- When the claim first-expense date is greater than '90365',
and HLD-TOT-EXP is greater than '100', then HLD-DED-TBM is
equal to '0'.
- When the claim first-expense date is greater than '90365',
and HLD-TOT-EXP is less than or equal to '100', then HLD-
DED-TBM is equal to '100' minus HLD-TOT-EXP.
- When the claim first-expense date is less then or equal to
'90365', and the HLD-TOT-EXP is greater than '75', then HLD-
DED-TBM is equal to '0'.
- When the claim first-expense date is less than or equal to
'90365', and the HLD-TOT-EXP is less then or equal to '75',
then HLD-DED-TBM is equal to '75' minus HLD-TOT-EXP.
HLD-MED-EXP (Outpatient claims)
_______________________________
This field is populated as follows:
NOTE: When the stay From Date on the Outpatient claim is equal to
the Beneficiary Part B year on the trailer table, set MATCH-
TRLR to true.
22
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the Outpatient deductible amount is greater than zero,
and MATCH-TRLR is not true, and the Outpatient stay from
year is less than the Beneficiary Part B fifth year, set
HLD-MED-EXP to MAX-CASH-DED-FOR-THIS-CLAIM.
- When the Outpatient deductible amount is greater than zero,
MATCH-TRLR is not true, and the Outpatient stay from year is
not less than the Beneficiary Part B fifth year, and the
Action Code on the claim is equal to '7', and the
Beneficiary Part B fifth year is the default value, and stay
from year is not less than the Beneficiary Part B year on
the trailer table, set HLD-MED-EXP to MAX-CASH-DED-FOR-THIS-
CLAIM.
- When the Outpatient deductible amount is not greater than
zero, the Action Code on the claim is equal to '7', and the
Outpatient stay from year is less than the Beneficiary Part
B year on the trailer table, or the stay from year is less
than the Beneficiary Part B fifth year, set HLD-MED-EXP to
MAX-CASH-DED-FOR-THIS-CLAIM.
- When the year of the stay From Date on the Outpatient claim
is equal to a Part B year in the Beneficiary trailer table,
set HLD-MED-EXP to the Part B medical expenses on the
Beneficiary record.
- When the year of the stay From Date on the Outpatient claim
is not equal to a Part B year in the Beneficiary trailer
table, set HLD-MED-EXP to zero.
HLD-MED-EXP
___________
HLD-MED-EXP is populated as follows:
- When the claim first-expense year is less than the current
year minus '4', and the claim first-expense year is greater
than '90', move '100.00' to HLD-MED-EXP.
- When the claim first-expense year is less than the current
year minus '4', and the claim first-expense year is less
than, or equal to, '90', move '75.00' to HLD-MED-EXP.
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', and the claim first-expense
year is equal to any of the first four history Part B year
entries, move the Beneficiary Part B deductible met amount
to HLD-MED-EXP.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, the claim first-expense date
is greater than, or equal to, '89001', and a match was not
found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
23
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
MED-EXP to zeros.
HLD-OTHPY-EXP
_____________
HLD-OTHPY-EXP is populated as follows:
- When the claim first-expense year is greater than or equal
to the current year minus '4', and the claim first-expense
year is equal to any of the first four history Part B year
entries, move the Beneficiary Part B occupational therapy
limitation amount to HLD-OTHPY-EXP.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, and the claim first-expense
date is greater than, or equal to, '89001', and a match was
not found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
OTHPY-EXP to zeros.
HLD-PSY-EXP (Outpatient claims)
___________
This field is populated as follows:
- When the year of the stay From Date on the Outpatient claim
is equal to a Part B year on the Beneficiary trailer table,
set HLD-PSY-EXP to the Beneficiary Part B psychiatric
expenses.
- When the year of the stay From Date on the Outpatient claim
is not equal to a Part B year on the Beneficiary trailer
table, set HLD-PSY-EXP to zero.
HLD-PSY-EXP
___________
HLD-PSY-EXP is populated as follows:
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', and the claim first-expense
year is equal to any of the first four history Part B year
entries, move the Beneficiary Part B psychiatric expense to
HLD-PSY-EXP.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, and the claim first-expense
date is greater than, or equal to, '89001', and a match was
not found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
PSY-EXP to zeros.
24
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
HLD-PTHPY-EXP
_____________
HLD-PTHPY-EXP is populated as follows:
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', and the claim first-expense
year is equal to any of the first four history Part B year
entries, move the Beneficiary Part B physical therapy
expense amount to HLD-PTHPY-EXP.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, the claim first-expense date
is greater than or equal to '89001', and a match was not
found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
PTHPY-EXP to zeros.
HLD-RICR-PSY
____________
HLD-RICR-PSY is populated as follows:
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', and the claim first-expense
year is equal to any of the first four history Part B year
entries, move the Beneficiary Part B RIC remaining
psychiatric expense amount to HLD-RICR-PSY.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, the claim first-expense date
is greater than, or equal to, '89001', and a match was not
found between the claim expense year and the Beneficiary
remaining Part A/B Blood Deductible Year, initialize HLD-
RICR-PSY to zeros.
HLD-RICR-OTHPY
______________
HLD-RICR-OTHPY is populated as follows:
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', the claim first-expense year
is equal to any of the first four history Part B year
entries, move the Beneficiary Part B RIC remaining OT
expense amount to HLD-RICR-OTHPY.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, the claim first-expense date
is greater than, or equal to, '89001', and a match was not
found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
RICR-OTHPY to zeros.
25
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
HLD-RICR-PTHPY
______________
HLD-RICR-PTHPY is populated as follows:
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', the claim first expense year
is equal to any of the first four history Part B year
entries, move the Beneficiary Part B RIC remaining PT
expense amount to HLD-RICR-PTHPY.
- If a match is not found in the first four history entries on
the Beneficiary Master Record, and the claim first-expense
date is greater than, or equal to, '89001', and a match was
not found between the claim expense year and the Beneficiary
Remaining Part A/B Blood Deductible Year, initialize HLD-
RICR-PTHPY to zeros.
HLD-TOT-EXP
___________
HLD-TOT-EXP is calculated as follows:
- When the claim first-expense date is greater than '88366',
then HLD-TOT-EXP is equal to HLD-MED-EXP.
- When the claim first-expense date is less than or equal to
'88366', then HLD-TOT-EXP is calculated by adding HLD-MED-
EXP to the total of '.625' multiplied by HLD-PSY-EXP.
HMO-PD-SW
_________
HMO-PD-SW is set in the following conditions:
- When the transaction identifier is a CLAIM-IS-HOSPICE,
bypass all conditional logic to set the HMO-PD-SW switch.
- The HMO-PD-SW switch is initially set to '0' before any
conditional logic is performed.
26
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the Beneficiary HMO indicator is not equal to '1', and
the HMO CHOICES ID is not equal to WS-CHOICES-ID, and the
HMO paid indicator is not equal to '1', skip to
immunosuppressive logic, and bypass remaining logic to set
HMO-PD-SW.
- Whenever HMO-PD-SW is assigned a value, it has been
determined that the claim is within either HMO period one or
HMO period two.
HMO period one edits
- When the Outpatient stay From Date is greater than '86000',
and greater than or equal to the Beneficiary HMO period one
Effective Date, and the Beneficiary HMO period one
Termination Date is equal to zero, set the HMO-PD-SW switch
to '1'.
- When the Outpatient stay From Date is greater than '86000'
and greater than, or equal to, the Beneficiary HMO period
one Effective Date and the Beneficiary HMO period one
Termination Date is not equal to zero, the stay From Date is
less than, or equal to, the HMO period one Termination Date,
set the HMO-PD-SW switch to '1'.
- When the Outpatient stay From Date is greater than '86000'
and not greater than, or equal to, the Beneficiary HMO
period one Effective Date, and the stay From Date is not
less than the HMO period two Effective Date and not greater
than the HMO period two Termination Date, set the HMO-PD-SW
switch to '2'.
- When the HMO period one Termination Date is equal to zero,
set the HMO-PD-SW switch to '1'.
- When the Outpatient stay Thru Date is not greater than the
HMO period one Termination Date, set the HMO-PD-SW switch to
'1'.
HMO period two edits
- When the Outpatient stay From Date is not less than the HMO
period two Effective Date, and the Outpatient stay Thru Date
is not greater than the HMO period two Termination Date, set
the HMO-PD-SW switch to '2'.
- When the Outpatient stay From Date is not less than the HMO
period two Effective Date, the Outpatient stay Thru Date is
greater than the HMO period two Termination Date, and the
Outpatient Data Indicator '25' is not less than '2', set the
HMO-PD-SW switch to '2'.
HOSPICE MASTER TABLES
_____________________
27
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
Two tables are used in Hospice processing to store election period
data for up to four periods. The Old Hospice Master Table is
built from records in the existing Hospice Auxiliary file. The
New Hospice Master Table is built from data on the Old Master
Table and on the incoming claim. Both the old and new Hospice
Master Tables reside on the internal claim processing record.
HOSPICE-NOE-ADD-BILL
____________________
This '88' level is true when the third position of the bill type
is equal to 'A'.
HOSPICE-NOE-BILL
________________
This '88' level is true when the third position of the bill type
is equal to 'A', 'B', 'C', or 'D'.
HSPM-START1-DATE
________________
This is the Hospice enrollment Start Date.
HSPM-TERM-DATE
______________
This is the last date of the Hospice enrollment (automatically
'90' days after the Start Date for the first and second enrollment
periods, '30' days for the third and fourth periods).
HSPM-TERM-SWITCH
________________
This switch is set to a '1' if the Beneficiary elects to
discontinue the Hospice enrollment, in which case the HSPM-TERM-
DATE is changed to the date that it is discontinued.
HUBC-DEMO-NUM-CABG-COE
______________________
This '88' level is true when the Demonstration Project Number is
equal to '06' (Coronary Artery Bypass Graft) or '07'
(Participating Center Of Excellence.)
28
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
HUBC-NON-PHYS-SPEC-CODES
________________________
This '88' level is true when HUBC-CMS-PROV-SPEC is equal to '42',
'43', '45', '49', '80', '50-59', '60-65', '67-69', '87-89', '95-
97', or 'A0-A8'.
HUBC-SLIDE-PREP-CODE
____________________
This '88' level is true when the Procedure Code is equal to
'88302', '88304', '88305', '88307', or '88309'.
HUIN-SNF-IND
____________
The following conditions will set the HUIN-SNF-IND to '2':
- When the first position of the bill type is equal to '2'
OR
- When the first two positions of the bill type are equal to
'18'
OR
- When the first two positions of the bill type are equal to
'51'
29
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
IMMUNO DRUG TABLE
_________________
Below is the actual working storage that defines the date and day
values used.
NOTE: The dates are in relative format.
*************************************************************
I M M U N O D R U G T A B L E
THIS TABLE DEFINES WHEN IMMUNO DRUG COVERAGE IS AVAILABLE
THE VALUES IN THIS TABLE SHOW THE FOLLOWING:
10 - EARLIEST TRANSPLANT DISCHARGE DATE RANGE
10 - LATEST TRANSPLANT DISCHARGE DATE RANGE
10 - NUMBER OF DAYS FROM DISCHARGE THE BENE IS COVERED
* 365 = 12 MONTHS
* 548 = 18 MONTHS
* 730 = 24 MONTHS
* 913 = 30 MONTHS
*1095 = 36 MONTHS
10 - EARLIEST DATE COVERAGE RESUMES FOR DRUGS
* IF THE DATE IS '+0' THEN NO MORE COVERAGE IS AVAILABLE
10 - LATEST DATE COVERAGE RESUMES FOR DRUGS
10 - TOTAL DAYS OF COVERAGE ALLOWED FOR THIS DRUG
*************************************************************
03 T-TPLANT-TABLE.
05 T-24TH-TRANSPLANT-RANGE.
10 T063095 PIC S9(05) BINARY VALUE +12599
10 T123199 PIC S9(05) BINARY VALUE +29584
10 T1095DAYS PIC S9(05) PACKED-DECIMAL VALUE +01095
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-24TH-DYS PIC S9(05) BINARY VALUE +01095.
05 T-23RD-TRANSPLANT-RANGE.
10 T053195 PIC S9(05) BINARY VALUE +12569.
10 T070195 PIC S9(05) BINARY VALUE +12600.
10 T1065DAYS PIC S9(05) PACKED-DECIMAL VALUE +01065.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-23RD-DYS PIC S9(05) BINARY VALUE +01065.
05 T-22ND-TRANSPLANT-RANGE.
10 T043095 PIC S9(05) BINARY VALUE +12538.
10 T060195 PIC S9(05) BINARY VALUE +12570.
10 T1035DAYS PIC S9(05) PACKED-DECIMAL VALUE +01035.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-22ND-DYS PIC S9(05) BINARY VALUE +01035.
30
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
05 T-21ST-TRANSPLANT-RANGE.
10 T033195 PIC S9(05) BINARY VALUE +12508.
10 T050195 PIC S9(05) BINARY VALUE +12539.
10 T1005DAYS PIC S9(05) PACKED-DECIMAL VALUE +01005.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-21ST-DYS PIC S9(05) BINARY VALUE +01005.
05 T-20TH-TRANSPLANT-RANGE.
10 T022895 PIC S9(05) BINARY VALUE +12477.
10 T040195 PIC S9(05) BINARY VALUE +12509.
10 T975DAYS PIC S9(05) PACKED-DECIMAL VALUE +00975.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-20TH-DYS PIC S9(05) BINARY VALUE +00975.
05 T-19TH-TRANSPLANT-RANGE.
10 T013195 PIC S9(05) BINARY VALUE +12449.
10 T030195 PIC S9(05) BINARY VALUE +12478.
10 T945DAYS PIC S9(05) PACKED-DECIMAL VALUE +00945.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-19TH-DYS PIC S9(05) BINARY VALUE +00945.
05 T-18TH-TRANSPLANT-RANGE.
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T020195 PIC S9(05) BINARY VALUE +12450.
10 T913DAYS PIC S9(05) PACKED-DECIMAL VALUE +00913.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-18TH-DYS PIC S9(05) BINARY VALUE +00913.
05 T-17TH-TRANSPLANT-RANGE.
10 T113094 PIC S9(05) BINARY VALUE +12387.
10 T010195 PIC S9(05) BINARY VALUE +12419.
10 T833DAYS PIC S9(05) PACKED-DECIMAL VALUE +00883.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-17TH-DYS PIC S9(05) BINARY VALUE +00883.
05 T-16TH-TRANSPLANT-RANGE.
10 T103194 PIC S9(05) BINARY VALUE +12357.
10 T120194 PIC S9(05) BINARY VALUE +12388.
10 T853DAYS PIC S9(05) PACKED-DECIMAL VALUE +00853.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-16TH-DYS PIC S9(05) BINARY VALUE +00853.
05 T-15TH-TRANSPLANT-RANGE.
10 T093094 PIC S9(05) BINARY VALUE +12326.
10 T110194 PIC S9(05) BINARY VALUE +12358.
10 T823DAYS PIC S9(05) PACKED-DECIMAL VALUE +00823.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
31
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
10 T-15TH- DYS PIC S9(05) BINARY VALUE +00823.
05 T-14TH-TRANSPLANT-RANGE.
10 T083194 PIC S9(05) BINARY VALUE +12296.
10 T100194 PIC S9(05) BINARY VALUE +12327.
10 T793DAYS PIC S9(05) PACKED-DECIMAL VALUE +00793.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-14TH-DYS PIC S9(05) BINARY VALUE +00793.
05 T-13TH-TRANSPLANT-RANGE.
10 T073194 PIC S9(05) BINARY VALUE +12265.
10 T090194 PIC S9(05) BINARY VALUE +12297.
10 T763DAYS PIC S9(05) PACKED-DECIMAL VALUE +00763.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-13TH-DYS PIC S9(05) BINARY VALUE +00763.
05 T-12TH-TRANSPLANT-RANGE.
10 T063094 PIC S9(05) BINARY VALUE +12234.
10 T080194 PIC S9(05) BINARY VALUE +12266.
10 T730DAYS PIC S9(05) PACKED-DECIMAL VALUE +00730.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-12TH-DYS PIC S9(05) BINARY VALUE +00730.
05 T-11TH-TRANSPLANT-RANGE.
10 T053194 PIC S9(05) BINARY VALUE +12204.
10 T070194 PIC S9(05) BINARY VALUE +12235.
10 T700DAYS PIC S9(05) PACKED-DECIMAL VALUE +00700.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-11TH-DYS PIC S9(05) BINARY VALUE +00700.
05 T-10TH-TRANSPLANT-RANGE.
10 T043094 PIC S9(05) BINARY VALUE +12173.
10 T060194 PIC S9(05) BINARY VALUE +12205.
10 T670DAYS PIC S9(05) PACKED-DECIMAL VALUE +00670.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-10TH-DYS PIC S9(05) BINARY VALUE +00670.
05 T-9TH-TRANSPLANT-RANGE.
10 T033194 PIC S9(05) BINARY VALUE +12143.
10 T050194 PIC S9(05) BINARY VALUE +12174.
10 T640DAYS PIC S9(05) PACKED-DECIMAL VALUE +00640.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-9TH-DYS PIC S9(05) BINARY VALUE +00640.
05 T-8TH-TRANSPLANT-RANGE.
10 T022894 PIC S9(05) BINARY VALUE +12112.
10 T040194 PIC S9(05) BINARY VALUE +12144.
10 T610DAYS PIC S9(05) PACKED-DECIMAL VALUE +00610.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
32
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-8TH-DYS PIC S9(05) BINARY VALUE +00610.
05 T-7TH-TRANSPLANT-RANGE.
10 T013194 PIC S9(05) BINARY VALUE +12084.
10 T030194 PIC S9(05) BINARY VALUE +12113.
10 T580DAYS PIC S9(05) PACKED-DECIMAL VALUE +00580.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-7TH-DYS PIC S9(05) BINARY VALUE +00580.
05 T-6TH-TRANSPLANT-RANGE.
10 T123193 PIC S9(05) BINARY VALUE +12053.
10 T020194 PIC S9(05) BINARY VALUE +12085.
10 T548DAYS PIC S9(05) PACKED-DECIMAL VALUE +00548.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-6TH-DYS PIC S9(05) BINARY VALUE +00548.
05 T-5TH-TRANSPLANT-RANGE.
10 T113093 PIC S9(05) BINARY VALUE +12022.
10 T010194 PIC S9(05) BINARY VALUE +12054.
10 T515DAYS PIC S9(05) PACKED-DECIMAL VALUE +00515.
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T060195 PIC S9(05) BINARY VALUE +12570.
10 T-5TH-DYS PIC S9(05) BINARY VALUE +00518.
05 T-4TH-TRANSPLANT-RANGE.
10 T103193 PIC S9(05) BINARY VALUE +11992.
10 T120193 PIC S9(05) BINARY VALUE +12023.
10 T485DAYS PIC S9(05) PACKED-DECIMAL VALUE +00485.
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T050195 PIC S9(05) BINARY VALUE +12539.
10 T-4TH-DYS PIC S9(05) BINARY VALUE +00488.
05 T-3RD-TRANSPLANT-RANGE.
10 T093093 PIC S9(05) BINARY VALUE +11961.
10 T110193 PIC S9(05) BINARY VALUE +11993.
10 T455DAYS PIC S9(05) PACKED-DECIMAL VALUE +00455.
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T040195 PIC S9(05) BINARY VALUE +12509.
10 T-3RD-DYS PIC S9(05) BINARY VALUE +00458.
05 T-2ND-TRANSPLANT-RANGE.
10 T083193 PIC S9(05) BINARY VALUE +11931.
10 T100193 PIC S9(05) BINARY VALUE +11962.
10 T425DAYS PIC S9(05) PACKED-DECIMAL VALUE +00425.
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T030195 PIC S9(05) BINARY VALUE +12478.
10 T-2ND-DYS PIC S9(05) BINARY VALUE +00428.
05 T-1ST-TRANSPLANT-RANGE.
10 T073193 PIC S9(05) BINARY VALUE +11900.
10 T090193 PIC S9(05) BINARY VALUE +11932.
10 T395DAYS PIC S9(05) PACKED-DECIMAL VALUE +00395.
33
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
10 T123194 PIC S9(05) BINARY VALUE +12418.
10 T020195 PIC S9(05) BINARY VALUE +12450.
10 T-1ST-DYS PIC S9(05) BINARY VALUE +00398.
05 T-0TH-TRANSPLANT-RANGE.
10 T010161 PIC S9(05) BINARY VALUE +00000.
10 T080193 PIC S9(05) BINARY VALUE +11901.
10 T365DAYS PIC S9(05) PACKED-DECIMAL VALUE +00365.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-NODATE PIC S9(05) BINARY VALUE +00000.
10 T-0TH-DYS PIC S9(05) BINARY VALUE +00365.
03 T-TRANSPLANT-TABLE REDEFINES
T-TPLANT-TABLE.
05 T-TRANSPLANT-TABLE
OCCURS 25 TIMES
*******************************************************************
*>>>>>>>>> MAXIMUM CONSTANT = C-MAX-TRANSPLANT-TABLE-ENTRIES *
*******************************************************************
INDEXED BY T-TP-NDX.
10 T-TRANSPLANT-FROM-DATE PIC S9(05) BINARY.
10 T-TRANSPLANT-TO-DATE PIC S9(05) BINARY.
10 T-TRANSPLANT-COVERED-DAYS PIC S9(05) PACKED-
DECIMAL.
10 T-TRANSPLANT-EXTEND-FROM-DATE PIC S9(05) BINARY.
'88' T-TRANSPLANT-NO-EXTENSION-FROM VALUE +0000.
10 T-TRANSPLANT-EXTEND-TO-DATE PIC S9(05) BINARY.
'88' T-TRANSPLANT-NO-EXTENSION-TO VALUE +0000.
10 T-TRANSPLANT-ALLOWED-DAYS PIC S9(05) BINARY.
MAMM-HIRISK
___________
This '88' level is true when the Type of Service is equal to 'B'.
MAMM-LOWRISK
____________
This '88' level is true when the Type of Service is equal to 'C'.
MAMMOGRAPHY-BILL
________________
This '88' level is true when the Type of Service is equal to 'B'
or 'C'.
34
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
MAMMOGRAPHY-BILL-PRESENT
________________________
This '88' level is true when the first two positions of the bill
type are equal to '14', '22', '23', or '85', or RHC-MAMMO-71X-
BILL, and the Revenue Code is equal to '0403'.
MAMM-SPAN-DATE-PRESENT
______________________
This '88' level is true when the Span Code is equal to '72' and
the span From Date is valid (return code zero From Date convert
routine).
MAMM-SPAN-DATE-VALID
____________________
This '88' level is true when the Span Code is equal to '72', and
the span From Date is valid (return code zero From Date convert
routine), and the span From Date is greater than '91000'.
MAX-CASH-DED-FOR-THIS-CLAIM
___________________________
This field is populated as follows:
- When the stay From Date on the Outpatient claim is numeric
and is greater than '91000', set MAX-CASH-DED-FOR-THIS-CLAIM
to '+100.00'.
- When the stay From Date on the Outpatient claim is numeric
and is not greater than '91000', set MAX-CASH-DED-FOR-THIS-
CLAIM to '+75.00'.
- When the stay From Date on the Outpatient claim is not
numeric, set MAX-CASH-DED-FOR-THIS-CLAIM to '+75.00'.
MSP-MATCHED
___________
This field is set as follows:
- This switch is initially set to true. Once the switch is
set to not true, the logic moves on to the next MSP
Auxiliary Record iteration.
- When the Contractor Number on the maintenance record is
equal to '66666' and the Contractor Number on the Auxiliary
record iteration is not equal to '66666', set the switch to
not true.
35
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the Medicare Secondary Payer (MSP) delete indicator on
the Auxiliary record iteration is equal to 'D', set the
switch to not true.
- When the MSP Code on the maintenance record does not equal
the MSP Code on the Auxiliary record iteration, set the
switch to not true.
- When the MSP patient relationship on the maintenance record
is not equal to the MSP patient relationship on the
Auxiliary record iteration,
AND
- When the MSP Code on the maintenance record is equal to 'A',
and the MSP patient relationship on the Auxiliary record
iteration equals '1' or '2', set the switch to not true.
- When the MSP Code on the maintenance record is equal to 'B'
or 'G', and the MSP patient relationship on the Auxiliary
record iteration is equal to '0' through '5' or '18', set
the switch to not true.
- When the MSP Code on the maintenance record is equal to 'D',
'E' or 'L', and the MSP Effective Date on the maintenance
record is not equal to the MSP Effective Date on the
Auxiliary record iteration, set the switch to not true.
- When the MSP Effective Date on the Auxiliary record
iteration minus the MSP Effective Date on the maintenance
record is greater than '+30' or less than '-30', and the
contractor number on the maintenance record and the
originating contractor number on the Auxiliary record
iteration are not both equal to '666666', set the switch to
not true.
NON-PPS-CLAIM
_____________
NON-PPS-CLAIM is set to true when a Condition Code '65' is present
on the claim.
NOT-CLIA-WAIVER-CAT69-MODQW
___________________________
This '88' level is initialized to true. When HCPCS Edit Category
'69', and when the Procedure Code Modifier '1' or '2' is equal to
'QW', set the switch to not true.
ONE-HUND-NOT-SUBJ
_________________
36
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
This '88' level is true when the CMS Reimbursement Indicator is
equal to '1' and the CMS deductible indicator is not equal to '0'.
ONE-HUND-SUBJ
_____________
This '88' level is true when the CMS Reimbursement Indicator is
equal to '1' and the CMS deductible indicator is equal to '0'.
OT
_______________
This '88' level is true when the Type of Service is equal to 'U'.
OUTPATIENT-TRANS-ID
___________________
OUTPATIENT-TRANS-ID is a representation of the claim transaction
ID when it is equal to 'HUOP', 'HBOP', or 'HIOP'.
PARTB-ENTRY
___________
This '88' level is true when the HUBC-REC-ID equals HUBC or HIBC.
PARTB-TRANS-ID
______________
PARTB-TRANS-ID is a representation of the claim transaction ID
when it is equal to 'HUBC', 'HBBC', or 'HIBC'.
PATIENT-STATUS-IS-DOD-HOSPICE
_____________________________
This '88' level is true when the claim patient status is equal to
'40', '41', or '42'.
POSCAT-PEN-PUMP
_______________
This '88' level is true when the HCPCS code is equal to 'B9000',
'B9001', 'B9002', 'B9004', or 'B9006'.
PP-IND
______
PP-IND is set as follows:
37
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- A '1' is moved to the PP-IND when:
- The HUIN-SNF-IND is not a '2'
AND
- There is not a Condition Code '65' on the bill
AND
- Positions '3-6' of the Medicare Provider Number are not
equal to '200-1299', '1990-2299', '3000-3099', '3300-3399',
or '4000-4499'
AND
- The third position of the Medicare Provider Number is not
'S', 'T', 'U', 'V', or 'W'
AND
- The stay Thru Date is greater than or equal to the PPS
Provider Effective Date. See PPS-TRANSITION-CLAIM-SW
glossary term to see how the PPS Provider Effective Date is
calculated.
- A '0' is moved to the PP-IND when:
- The HUIN-SNF-IND is equal to a '2' OR
- There is a Condition Code '65' on the bill OR
- Positions '3-6' of the Medicare Provider Number are equal to
'1200-1299', '1990-2299', '3000-3099', '3300-3399', or
'4000-4499' OR
- The third position of the Medicare Provider Number is equal
to 'S', 'T', 'U', 'V', or 'W'
OR
- The stay Thru Date is less than the PPS Provider Effective
Date. See PPS-TRANSITION-CLAIM-SW glossary term to see how
the PPS Provider Effective Date is calculated.
PPS-TRANSITION-CLAIM-SW
_______________________
A 'Y' is moved to the PPS-TRANSITION-CLAIM-SW when:
- The HUIN-SNF-IND is not a '2'
AND
38
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- There is not a Condition Code '65' on the bill
AND
- Positions '3-6' of the Medicare Provider Number are not
equal to '1200-1299', '1990-2299', '3000-3099', '3300-3399',
or '4000-4499'
AND
- The third position of the Medicare Provider Number is not
'S', 'T', 'U', 'V', or 'W'
AND
- The stay Thru Date is greater than or equal to the PPS
Provider Effective Date
AND
- The stay From Date is equal to the PPS Provider Effective
Date
AND
- The Admit Date is less than the PPS Provider Effective Date
NOTE: If all the above conditions are true, the stay From Date is
equal to the stay Thru Date, and the patient status is not a
'30', a '1' is moved to the PPS-TRANSITION-CLAIM-SW.
ADDITIONAL NOTE: See HUIN-SNF-IND in this section for more detail
on this indicator.
The PPS Provider Effective Date is derived from internal tables
shown below) in the program HUIPCED as follows:
- It is initially defaulted to '83274'.
- If the first two positions of the Provider Number equal an
entry on the 'PPS State Code Table', the Date for this entry
is taken from the table and is used as the PPS Provider
Effective Date.
- If the Provider Number equals an entry on the 'PPS Provider
Number Table', the date for this entry is taken from the
table and is used as the PPS Provider Effective Date,
overriding the default value and any value taken from the
'PPS State Code Table'.
39
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
****************************************************************
****************************************************************
** THE FOLLOWING TABLE CONTAINS THE PPS EFFECTIVE DATES FOR **
** STATES THAT DID not BECOME EFFECTIVE ON THE DEFAULT DATE. **
** THIS TABLE SHOULD BE IN NUMERICAL ORDER BY STATE. STATES **
** THAT HAVE not CONVERTED TO PPS SHOULD HAVE A 1/1/99 **
** EFFECTIVE DATE IN THIS TABLE. **
****************************************************************
****************************************************************
01 PPS-STATE-EFFECTIVE-TABLE
05 PPS-STATE-MAXIMUM PIC 9(4) COMP VALUE 9.
05 PPS-STATE-DATA.
10 S-MARYLAND PIC X(07) VALUE '2199001'.
10 S-MASSACHUSETTS PIC X(07) VALUE '2285274'.
10 S-NEW-JERSEY PIC X(07) VALUE '3189001'.
10 S-NEW-YORK PIC X(07) VALUE '3386001'.
10 S-PUERTO-RICO PIC X(07) VALUE '4087274'.
10 S-VIRGIN-ISLANDS PIC X(07) VALUE '4899001'.
10 S-CANADA PIC X(07) VALUE '5699001'.
10 S-MEXICO PIC X(07) VALUE '5999001'.
10 S-SAMOA PIC X(07) VALUE '6499001'.
10 S-GUAM PIC X(07) VALUE '6599001'.
10 S-UNKNOWN PIC X(07) VALUE '9999001'.
05 PPS-STATE-ENTRIES REDEFINES PPS-STATE-DATA.
10 PPS-STATE-ENTRY OCCURS 11 TIMES
INDEXED BY PPS-STATE-IDX.
15 PPS-ST-CODE PIC X(02).
15 PPS-ST-EFFDT PIC 9(05).
***************************************************************
***************************************************************
** THE FOLLOWING TABLE CONTAINS THE PPS EFFECTIVE DATES FOR **
** PROVIDERS THAT WERE CONVERTED TO PPS AFTER THE STATE THAT **
** THEY ARE LOCATED IN WENT THROUGH GENERAL CONVERSION. **
** THIS TABLE SHOULD BE IN NUMERICAL ORDER BY PROVIDER. **
***************************************************************
***************************************************************
01 PPS-PROV-EFFECTIVE-TABLE
05 PPS-PROV-MAXIMUM PIC 9(4) COMP VALUE 6.
05 PPS-PROV-DATA.
10 FILLER PIC X(11) VALUE '33003091001'.
10 FILLER PIC X(11) VALUE '33005891001'.
10 FILLER PIC X(11) VALUE '33007491001'.
10 FILLER PIC X(11) VALUE '33009791001'.
10 FILLER PIC X(11) VALUE '33011091001'.
10 FILLER PIC X(11) VALUE '33015499001'.
10 FILLER PIC X(11) VALUE '33025491001'.
10 FILLER PIC X(11) VALUE '33035499001'.
10 FILLER PIC X(11) VALUE '33036299001'.
10 FILLER PIC X(11) VALUE '33036399001'.
10 FILLER PIC X(11) VALUE '33036699001'.
10 FILLER PIC X(11) VALUE '33036799001'.
10 FILLER PIC X(11) VALUE '33036899001'.
40
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
10 FILLER PIC X(11) VALUE '33036999001'.
10 FILLER PIC X(11) VALUE '33037199001'.
10 FILLER PIC X(11) VALUE '33037399001'.
10 FILLER PIC X(11) VALUE '33037899001'.
05 PPS-PROV-ENTRIES REDEFINES PPS-PROV-DATA.
10 PPS-PROV-ENTRY OCCURS '17' TIMES
INDEXED BY PPS-PROV-IDX.
15 PPS-PR-PROV PIC X(06).
15 PPS-PR-EFFDT PIC 9(05).
PRI-PAY-AMT (Outpatient claims)
___________
This field is accumulated for each Value Code on the claim. It is
calculated as follows:
- When the Value Code is greater than '11' and less than '17',
or the Value Code is greater than '40' and less than '44',
or the Value Code is equal to '47', the value amount for
that code is added to PRI-PAY-AMT.
PRI-PAY-AMT
___________
This field is accumulated for each Value Code on the claim. It is
calculated as follows:
- When the Value Code is greater than '11' and less than '17',
or the Value Code is greater than '40' and less than '44',
or the Value Code is equal to '47', the value amount for
that code is added to PRI-PAY-AMT.
PROFESSIONAL-BILL-SW
____________________
For Outpatient transaction codes, this switch is always set to
'N'.
For Part B claims:
- When the Procedure Code Modifier 1 or 2 is not equal to 'TC'
or '26', move 'Y' to this switch.
PROCESS-L1002-REPROCESS-PATH
____________________________
This '88' level is true when the Combine Spell Process has been
initiated and a history claim that is part of the second, or more
current spell, is being reprocessed as a new incoming claim.
PSYC
41
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
____
This '88' level is true when the Type of Service is equal to 'T'.
PT
__
This '88' level is true when the Type of Service is equal to 'W'.
QUAL-BYPASS-SW
______________
The following conditions will set the QUAL-BYPASS-SW to 'Y':
- When the HUIN-SNF-IND is equal to '2'
AND
- When the Condition Code is equal to '16'
AND
- When the Admission year is equal to '89'
AND
- When the stay thru year is greater than '89'
OR
- When the Admission year is equal to '89'
AND
- When the stay from year is equal to '89'
AND
- When the stay thru year is equal to '89'
OR
- When the Admission year is equal to '89'
AND
- When the stay from year is equal to '89'
AND
- When the stay Thru Date is equal to '90001'
AND
42
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the patient status is not equal to '30'
OR
- When the Condition Code is equal to '16'
AND
- When the Admission year is equal to '89'
REIMB-SW
________
This switch is set to true when any of the following edit errors
are present:
'92X1', '92X2', '92X3', '92X4', '92X5', '93X1', '93X2', '93X3',
'93X4', '93X5', '95X3', '96X2', '72X1', '72X2', or '72X3'.
RETRIEVE-HISTORY
________________
The RETRIEVE-HISTORY switch is set as follows:
- When the incoming Outpatient service Thru Date is greater
than, or equal to, the history Outpatient service From Date,
and the incoming Outpatient service From Date is less than,
or equal to, the history Outpatient service Thru Date, move
'Y' to RETRIEVE-HISTORY.
- When the incoming Outpatient service From Date is less than,
or equal to, the history Outpatient service From Date plus
one month (the month value MM in the date format of YY/MM/DD
is incremented by one and adjusted if adding one forces the
date to span to the next year), move 'Y' to RETRIEVE-
HISTORY.
- When the incoming Outpatient service Thru Date is less than,
or equal to, the history Outpatient service From Date plus
three months (the month value MM in the date format of
YY/MM/DD is incremented by three and adjusted if adding
three forces the date to span to the next year), move 'Y' to
RETRIEVE-HISTORY.
RHC-MAMMO-71X-BILL-SW
_____________________
When the first two positions of the bill type are equal to '71',
43
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
and positions '3-6' of the Provider Number are in the range '3975-
3999', '8500-8899', or '3400-3499', set the RHC-MAMMO-71X-BILL-SW
to 'Y' (RHC-MAMMO-71X-BILL becomes true).
S-CHOICES-BENE
______________
S-CHOICES-BENE is set to true when the HMO number from the HMO
Auxiliary file is equal to WS-CHOICES-ID or WS-ESRD-MANAGE-CARE-
ID.
S-CHOICES-HMO
_____________
This '88' level is true when the Beneficiary HMO plan number is a
WS-CHOICES-ID and the claim plan number is a WS-CHOICES-ID, and
the Beneficiary HMO plan number is equal to the claim plan number.
S-CLAIM-CANCELLED
_________________
This '88' level is set as follows:
For Inpatient claim types:
- When the fiscal Intermediary claim control number from the
bill on history is equal to CA-CAN-CRD-ICN, and the
Cancellation Date is not equal to zero, set the S-CLAIM-
CANCELLED to true.
For Outpatient claim types:
- When CLAIM-IS-HOSPICE, the table of Hospice history pointers
is searched to find the claim. Otherwise, the table of
Outpatient history pointers is searched. Three separate
searches are done in the pointer tables. The first search
looks for a year and month match between the history file
and claim, the second looks for only a year match, and the
third will search for a match among the remaining table
entries not searched. W-PTR-INDEX is the history pointer
table index used in this processing. W-SEARCH-CRITERIA-INDEX
is incremented from '+1' up to '+3', indicating which
search, as mentioned above, is currently being performed.
NOTE: WS-COMPARE-ICN is set as follows:
- When the claim Action Code is equal to '4', set WS-
COMPARE-ICN to the Intermediary control number from
the claim.
- When the claim Action Code is equal to '5', set WS-
COMPARE-ICN to the original Intermediary control
44
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
number from the claim.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is equal
to '+3', the read to the Hospice history file is successful,
and the History Intermediary Control Number is equal to WS-
COMPARE-ICN,
AND
- When the history Cancel Date is not equal to zero, or the
History bill type is not equal to '815' or '825', set S-
CLAIM-CANCELLED to true.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is not
equal to '+3', and the History From Date (W-PTR-INDEX) is
greater than or equal to the first day of the current year
and less than the first day of the following year, and W-
SEARCH-CRITERIA-INDEX is not equal to '+1', and the History
record Intermediary Control Number is equal to WS-COMPARE-
ICN,
AND
- When the history Cancel Date is not equal to zero, and the
History bill type is not equal to '815' or '825', set S-
CLAIM-CANCELLED to true.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is not
equal to '+3', and the History From Date (W-PTR-INDEX) is
greater than, or equal to the first day of the current year
and less than the first day of the following year, W-SEARCH-
CRITERIA-INDEX is equal to '+1', the History From Date (W-
PTR-INDEX) is greater than, or equal to, the first day of
the current month and less than the first day of the
following month, the History record Intermediary Control
Number is equal to WS-COMPARE-ICN,
AND
- When the history Cancel Date is not equal to zero, and the
History bill type is not equal to '815' or '825', set S-
CLAIM-CANCELLED to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
equal to '+3', the read to the Outpatient history file is
successful, the History intermediary Control Number is equal
to WS-COMPARE-ICN, and the history Cancel Date is not equal
to zero, set S-CLAIM-CANCELLED to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
not equal to '+3', the History From Date (W-PTR-INDEX) is
greater than, or equal to, the first day of the current year
and less than the first day of the following year, W-SEARCH-
CRITERIA-INDEX is not equal to +1, the History record
Intermediary Control Number is equal to WS-COMPARE-ICN, and
45
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
the history Cancel Date is not equal to zero, set S-CLAIM-
CANCELLED to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
not equal to '+3', the History From Date (W-PTR-INDEX) is
greater than, or equal to, the first day of the current year
and less than the first day of the following year, W-SEARCH-
CRITERIA-INDEX is equal to '+1', the History From Date (W-
PTR-INDEX) is greater than, or equal to, the first day of
the current month and less than the first day of the
following month, the History record Intermediary Control
Number is equal to WS-COMPARE-ICN, and the history Cancel
Date is not equal to zero, set S-CLAIM-CANCELLED to true.
S-CLAIM-FOUND
_____________
This '88' level is set as follows:
For Inpatient claim types:
- When the fiscal intermediary claim control number from the
bill on history is equal to CA-CAN-CRD-ICN, and the
Cancellation Date is equal to zero, set the S-CLAIM-FOUND to
true.
For Outpatient claim types:
- When CLAIM-IS-HOSPICE, the table of Hospice history pointers
is searched to find the claim. Otherwise, the table of
Outpatient history pointers is searched. Three separate
searches are done on the pointer tables. The first search
looks for a year and month match between the history file
and claim, the second looks for only a year match, and the
third will search for a match among the remaining table
entries not searched.
- W-PTR-INDEX is the history pointer table index used in this
processing. W-SEARCH-CRITERIA-INDEX is incremented starting
from '+1' up to '+3', indicating which search, as mentioned
above, is currently being performed.
NOTE: WS-COMPARE-ICN is set as follows:
- When the claim Action Code is equal to '4', set WS-
COMPARE-ICN to the Intermediary control number from
the claim.
- When the claim Action Code is equal to '5', set WS-
COMPARE-ICN to the original Intermediary control
number from the claim.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is equal
to '+3', the read to the Hospice history file is successful,
46
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
the History Intermediary Control Number is equal to WS-
COMPARE-ICN,
AND
- When the history Cancel Date is equal to zero, or the
history bill type is equal to '815' or '825', set S-CLAIM-
FOUND to true.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is not
equal to '+3', the History From Date (W-PTR-INDEX) is
greater than, or equal to, the first day of the current year
and less than the first day of the following year, W-SEARCH-
CRITERIA-INDEX is not equal to '+1', the History record
Intermediary Control Number is equal to WS-COMPARE-ICN,
AND
- When the history Cancel Date is equal to zero, or the
History bill type is equal to '815' or '825', set S-CLAIM-
FOUND to true.
- When CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is not
equal to '+3', and the History From Date (W-PTR-INDEX) is
greater than, or equal to, the first day of the current year
and less than the first day of the following year, W-SEARCH-
CRITERIA-INDEX is equal to '+1', the History From Date (W-
PTR-INDEX) is greater than, or equal to, the first day of
the current month and less than the first day of the
following month, and the History record Intermediary Control
Number is equal to WS-COMPARE-ICN,
- When the history Cancel Date is equal to zero, or the
History bill type is equal to '815' or '825', set S-CLAIM-
FOUND to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
equal to '+3', the read to the Outpatient history file is
successful, and the History Intermediary Control Number is
equal to WS-COMPARE-ICN, and the history Cancel Date is
equal to zero, set S-CLAIM-FOUND to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
not equal to '+3', and the History From Date (W-PTR-INDEX)
is greater than or equal to the first day of the current
year and less than the first day of the following year, and
W-SEARCH-CRITERIA-INDEX is not equal to '+1', and the
History record Intermediary Control Number is equal to WS-
COMPARE-ICN, and the history Cancel Date is equal to zero,
set S-CLAIM-FOUND to true.
- When not CLAIM-IS-HOSPICE, and W-SEARCH-CRITERIA-INDEX is
not equal to '+3', and the History From Date (W-PTR-INDEX)
is greater than or equal to the first day of the current
year and less than the first day of the following year, and
47
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
W-SEARCH-CRITERIA-INDEX is equal to '+1', and the History
From Date (W-PTR-INDEX) is greater than or equal to the
first day of the current month and less than the first day
of the following month, and the History record Intermediary
Control Number is equal to WS-COMPARE-ICN, and the history
Cancel Date is equal to zero, set S-CLAIM-FOUND to true.
S-CONDITION-CODE-M1-PRESENT
___________________________
This '88' level is true when there is a Condition Code 'M1'
present.
S-FIND-NON-PPS-BILL
___________________
This '88' level is true when the Inpatient claim contains a
Condition Code '65'.
S-FLU-OR-PNEUMO-HCPC-PRESENT
____________________________
This '88' level is true when there are Revenue Codes and HCPCS
present for either Flu or Pneumococcal services.
S-HMO-STATUS
____________
S-HMO-STATUS is set as follows:
- This main switch has five references to its contents. They
are: S-NOT-WITHIN-HMO, S-WITHIN-PRIOR-HMO, S-WITHIN-CURR-
HMO, S-OVERLAP-PRIOR-HMO, and S-OVERLAP-CURR-HMO. These
switches are set as follows:
- For the S-NOT-WITHIN-HMO to be true, S-HMO-STATUS must equal
'A'.
- For the S-WITHIN-PRIOR-HMO to be true, S-HMO-STATUS must
equal 'B'.
- For the S-WITHIN-CURR-HMO to be true, S-HMO-STATUS must
equal 'C'.
- For the S-OVERLAP-PRIOR-HMO to be true, S-HMO-STATUS must
equal 'D'.
- For the S-OVERLAP-CURR-HMO to be true, S-HMO-STATUS must
equal 'E'.
- The initial value is set to S-NOT-WITHIN-HMO being set to
true.
48
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- The assignments of this switch is processed as follows:
B310-HMO-DATE-EDIT.
- When the Beneficiary (HMO) Termination Date of period one
equals zeros, evaluate the following:
- When the claim last-expense date is less than the
Beneficiary (HMO) Effective Date for period one
AND
- The number of HMO periods is greater than '1', PERFORM B500-
CHECK-PRIOR-HMO.
- When the claim last-expense date is less than the
Beneficiary (HMO) Effective Date for period one, do not
change the setting of this switch.
- When the claim last-expense date is greater than or equal to
the Beneficiary (HMO) Effective Date for period one
AND
- The claim first-expense date is less than the Beneficiary
(HMO) Effective Date for period one, set S-OVERLAP-CURR-HMO
to true when the number of HMO periods if greater than '1',
PERFORM B500-CHECK-PRIOR-HMO
- When none of the above conditions are true, set S-WITHIN-
CURR-HMO to true.
- When the Beneficiary (HMO) Termination Date of period one
does not equal zeros, evaluate the following:
- When the claim last-expense date is less than the
Beneficiary (HMO) Effective Date for period one
AND
- The number of HMO periods is greater than '1', PERFORM
B500-CHECK-PRIOR-HMO.
- When the claim first-expense date is greater than the
Beneficiary (HMO) Termination Date for period one, do
not change the setting of this switch.
- When the claim last-expense date is less than or equal
to the Beneficiary (HMO) Termination Date for period
one
AND
- The claim first-expense date is greater than or equal
49
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
to the Beneficiary (HMO) Effective Date for period
one, set S-WITHIN-CURR-HMO to true.
- When the claim first-expense date is greater than or
equal to the Beneficiary (HMO) Effective Date for
period one
AND
- The claim last-expense date is greater than the
Beneficiary (HMO) Termination Date for period one, set
S-OVERLAP-CURR-HMO to true.
- When the claim last-expense date is greater than or
equal to the Beneficiary (HMO) Effective Date for
period one
AND
- The claim first-expense date is less than the
Beneficiary (HMO) Effective Date for period one, set
S-OVERLAP-CURR-HMO to true.
- When the number of HMO periods is greater than '1',
PERFORM B500-CHECK-PRIOR-HMO
- When none of the above conditions are true, do not
change the setting of this switch.
END OF B310-HMO-DATE-EDIT paragraph.
B500-CHECK-PRIOR-HMO.
When the S-OVERLAP-CURR-HMO is set to true evaluate the following:
- When the Beneficiary (HMO) Termination Date for period two
equals the Beneficiary (HMO) Effective Date for period one
AND
- The claim first-expense date is greater than or equal to the
Beneficiary (HMO) Effective Date for period two, set S-
WITHIN-PRIOR-HMO to true.
- When the claim first-expense date is greater than or equal
to the Beneficiary (HMO) Effective Date for period two
AND
- When the Beneficiary (HMO) Termination Date for period two
plus '1' equals the Beneficiary (HMO) Effective Date for
period one, set S-WITHIN-PRIOR-HMO to true.
When the S-OVERLAP-CURR-HMO is not set to true evaluate the
following:
50
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the claim last-expense date is less than the
Beneficiary (HMO) Effective Date of period two, set the S-
NOT-WITHIN-HMO to true.
- When the claim first-expense date is greater than or equal
to the Beneficiary (HMO) Effective Date for period two
AND
- The claim last-expense date is less than or equal to the
Beneficiary (HMO) Termination Date of period two, set the S-
WITHIN-PRIOR-HMO to true.
- When the claim first-expense date is greater than the
Beneficiary (HMO) Termination Date for period two
AND
- The claim last-expense date is less than the Beneficiary
(HMO) Effective Date for period one, set S-NOT-WITHIN-HMO to
true.
- When none of the above conditions are true, set S-OVERLAP-
PRIOR-HMO to true.
END OF B500-CHECK-PRIOR-HMO paragraph.
SLOT-1ST-PROVIDER-CO
____________________
NOTE: (SUBH) is the index for the new Hospice Table pointing to
the most recent entitlement period where the first Start
Date for the period is less than, or equal to, the claim
From Date.
The following conditions will set SLOT-1ST-PROVIDER-CO to true:
- When the delete code is less than, or equal to, spaces, the
second Hospice Provider Start Date (SUBH) is not equal to
zero, the From Date on the Hospice claim is less than the
second Hospice Provider Start Date (SUBH), the first Hospice
Provider Change of Ownership Start Date (SUBH) is not equal
to '0', and the From Date on the Hospice claim is greater
than, or equal to, the first Hospice Provider Change of
Ownership Start Date (SUBH), set SLOT-1ST-PROVIDER-CO to
true.
- When the delete code is less than, or equal to, spaces, the
second Hospice Provider Start Date (SUBH) is equal to zero,
the first Hospice Provider Change of Ownership Start Date
(SUBH) is not equal to '0', and the From Date on the Hospice
claim is greater than, or equal to, the first Hospice
Provider Change of Ownership Start Date (SUBH), set SLOT-
51
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
1ST-PROVIDER-CO to true.
SLOT-2ND-PROVIDER
_________________
NOTE: (SUBH) is the index for the new Hospice Table pointing to
the most recent entitlement period where the first Start
Date for the period is less than, or equal to, the claim
From Date.
The following conditions will set SLOT-2ND-PROVIDER to true:
- When the delete code is less than or equal to spaces, the
second Hospice Provider Start Date (SUBH) is not equal to
zero, the From Date on the Hospice claim is greater than, or
equal to, the second Hospice Provider Start Date (SUBH), the
second Hospice Provider Change of Ownership Start Date
(SUBH) is not equal to zero, and the From Date on the
Hospice claim is less than the second Hospice Provider
Change of Ownership Start Date (SUBH), set SLOT-2ND-PROVIDER
to true.
- When the delete code is less than or equal to spaces, the
second Hospice Provider Start Date (SUBH) is not equal to
zero, the From Date on the Hospice claim is greater than, or
equal to, the second Hospice Provider Start Date (SUBH), and
the second Hospice Provider Change of Ownership Start Date
(SUBH) is equal to zero, set SLOT-2ND-PROVIDER to true.
SLOT-2ND-PROVIDER-CO
____________________
NOTE: (SUBH) is the index for the new Hospice Table pointing to
the most recent entitlement period where the first Start
Date for the period is less than, or equal to, the claim
From Date.
The following conditions will set SLOT-2ND-PROVIDER-CO to true:
- When the delete code is less than, or equal to, spaces, the
second Hospice Provider Start Date (SUBH) is not equal to
zero, the From Date on the Hospice claim is greater than, or
equal to, the second Hospice Provider Start Date (SUBH), the
second Hospice Provider Change of Ownership Start Date
(SUBH) is not equal to zero, and the From Date on the
Hospice claim is greater than, or equal to, the second
Hospice Provider change of ownership Start Date (SUBH), set
SLOT-2ND-PROVIDER-CO to true.
S-MAMMO-REV-HCPC-PRESENT
________________________
52
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
This '88' level is true when there are Revenue Codes and HCPCS
present for mammography services.
S-NOT-FIND-NON-PPS-BILL
_______________________
This '88' level is true when the Inpatient or claim does not
contain a Condition Code '65'.
S-NOT-FIND-NON-PPS-BILL
_______________________
This '88' level is true when the Inpatient claim does not contain
a Condition Code '65'.
SPECIAL-BIC-SEX
_______________
The Sex Code is moved to a work area and the HIEBCIC module is
called. The Sex Code is populated and sent back to the calling
program.
START1-CHANGED
______________
This '88' level is set as follows:
NOTE: SUB-OLD is an index for the Old Hospice Master Table. It is
set to '1' initially, and incremented by '1' after each
table entry is processed until it is greater than '4'.
- When the third position of the claim bill type is equal to
'B', and the Hospice claim From Date is equal to the first
Hospice Provider Start Date (SUB-OLD) on the old Hospice
Table, the Intermediary number on the claim is equal to the
first Hospice Intermediary number (SUB-OLD) on the old
Hospice Table, the Medicare Provider Number on the claim is
equal to the first Hospice Provider Number (SUB-OLD) on the
old Hospice Table, set START1-CHANGED to true.
- When the third position of the claim bill type is not equal
to 'B', the original Start Date on the claim is equal to the
first Hospice Provider Start Date (SUB-OLD) on the old
Hospice Table, and the Medicare Provider Number on the claim
is equal to the first Hospice Provider Number (SUB-OLD) on
the old Hospice Table, set START1-CHANGED to true.
START1-CO-CHANGED
_________________
This '88' level is set as follows:
53
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
NOTE: SUB-OLD is an index for the Old Hospice Master Table. It
is set to '1' initially, and incremented by '1' after each
table entry is processed until it is greater than '4'.
- When the third position of the claim bill type is equal to
'B', the Hospice claim From Date is equal to the first
Hospice Provider Change of Ownership Start Date (SUB-OLD) on
the old Hospice Table, the Intermediary Number on the claim
is equal to the first Hospice Change of Ownership
Intermediary Number (SUB-OLD) on the old Hospice Table, and
the Medicare Provider Number on the claim is equal to the
first Hospice Provider Change of Ownership Number (SUB-OLD)
on the old Hospice Table, set START1-CO-CHANGED to true.
- When the third position of the claim bill type is not equal
to 'B', the original Start Date on the claim is equal to the
first Hospice Provider Change of Ownership Start Date (SUB-
OLD) on the old Hospice Table, and the Medicare Provider
Number on the claim is equal to the first Hospice Provider
Change of Ownership Number (SUB-OLD) on the old Hospice
Table, set START1-CO-CHANGED to true.
START2-CHANGED
______________
This '88' level is set as follows:
NOTE: SUB-OLD is an index for the Old Hospice Master Table. It is
set to '1' initially, and incremented by '1' after each
table entry is processed, until it is greater than '4'.
- When the third position of the claim bill type is equal to
'B', the Hospice claim From Date is equal to the second
Hospice Provider Start Date (SUB-OLD) on the old Hospice
Table, the Intermediary Number on the claim is equal to the
second Hospice Intermediary number (SUB-OLD) on the old
Hospice Table, and the Medicare Provider Number on the claim
is equal to the second Hospice Provider Number (SUB-OLD) on
the old Hospice Table, set START2-CHANGED to true.
- When the third position of the claim bill type is not equal
to 'B', the original Start Date on the claim is equal to the
second Hospice Provider Start Date (SUB-OLD) on the old
Hospice Table, the Medicare Provider Number on the claim is
equal to the second Hospice Provider Number (SUB-OLD) on the
old Hospice Table, set START2-CHANGED to true.
START2-CO-CHANGED
_________________
This '88' level is set as follows:
54
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
NOTE: SUB-OLD is an index for the Old Hospice Master Table. It
is set to '1' initially, and incremented by '1' after each
table entry is processed, until it is greater than '4'.
- When the third position of the claim bill type is equal to
'B', the Hospice claim From Date is equal to the second
Hospice Provider Change of Ownership Start Date (SUB-OLD) on
the old Hospice Table, the Intermediary number on the claim
is equal to the second Hospice Change of Ownership
Intermediary Number (SUB-OLD) on the old Hospice Table, and
the Medicare Provider Number on the claim is equal to the
second Hospice Provider Change of Ownership Number (SUB-OLD)
on the old Hospice Table, set START2-CO-CHANGED to true.
- When the third position of the claim bill type is not equal
to 'B', the original Start Date on the claim is equal to the
second Hospice Provider Change of Ownership Start Date (SUB-
OLD) on the old Hospice Table, and the Medicare Provider
Number on the claim is equal to the second Hospice Provider
Change of Ownership Number (SUB-OLD) on the old Hospice
Table, set START2-CO-CHANGED to true.
STATES-TO-BYPASS-CLIA
_____________________
This '88' level is true when the first three position of the CLIA
number are equal to '33D', '38D', or '50D'.
SW-HOSPICE-STATUS
_________________
SW-HOSPICE-STATUS is set as follows:
- This main switch has three references to its contents. They
are: SW-NOT-IN-HOSPICE-PERIOD, SW-WITHIN-HOSPICE-PERIOD, SW-
WITHIN-REVOKE-MONTH.
- For the SW-NOT-IN-HOSPICE-PERIOD to be true, SW-HOSPICE-
STATUS must equal '0'.
- For the SW-WITHIN-HOSPICE-PERIOD to be true, SW-HOSPICE-
STATUS must equal '1'.
- For the SW-WITHIN-REVOKE-MONTH to be true, SW-HOSPICE-STATUS
must equal '2'.
- The initial value is set to SW-NOT-IN-HOSPICE-PERIOD being
set to true.
- The assignment of this switch is completed during a loop
process of examining the Hospice entries on the Hospice
record. It is important to know this as the exact HOSP
entry is not referenced in the data compares.
While processing an HOSP entry at a time, evaluate the following:
55
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the Hospice Start Date equal zeros, do not change the
setting of this switch.
- When the claim Last-Expense Date is less than, or equal to,
Hospice Start Date, do not change the setting of this
switch.
- When the claim First-Expense Date is greater than the
Hospice Termination Date, and the Hospice Revocation
Indicator is other than '0', PERFORM B850-MEDICARE-
LIABILITY-DATE.
- When the claim First-Expense Date is greater than the
Hospice Termination Date and the Hospice Revocation
Indicator does is equal to '0', set SW-WITHIN-HOSPICE-PERIOD
to true.
- When the claim first-expense date equals the Hospice
Termination Date, and the Hospice Revocation Indicator is
other than '0', set SW-WITHIN-REVOKE-MONTH to true.
- When the claim first-expense date equals the Hospice
Termination Date, and the Hospice Revocation Indicator is
equal to '0', set SW-WITHIN-Hospice-PERIOD to true.
- When none of the above conditions are true, set SW-WITHIN-
HOSPICE-PERIOD to true.
PERFORM B850-MEDICARE-LIABILITY-DATE:
- Convert the Hospice Termination Date to a MM/DD/YY format
into a hold date field.
- Alter this hold date field to be the first of the next
calendar month (i.e. when date equals '120394', this changed
hold date will be '010195').
- Convert this first of the month hold date to a signed Julian
date.
- When the claim First-Expense Date is greater than, or equal
to, this signed Julian date, set SW-NOT-IN-HOSPICE-PERIOD to
true.
- When the claim First-Expense Date is less than this signed
Julian date, set SW-WITHIN-REVOKE-MONTH to true.
- End of B850-MEDICARE-LIABILITY-DATE paragraph.
TECHNICAL-BILL-SW
_________________
For Outpatient transaction codes, this switch is always set to
'Y'.
56
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
For Part B claims, this switch is set to 'Y' when the Procedure
Code Modifier '1' is equal to 'TC', or the Procedure Code Modifier
'2' is equal to 'TC'.
TELEMEDICINE-PROJECT-HCPCS
__________________________
This '88' level is true when the Procedure Code is in the range
of:
'QQ211-QQ215', 'QQ221-QQ223', 'QQ231-QQ233', 'QQ241-QQ245',
'QQ251-QQ255', 'QQ261-QQ263', 'QQD21-QQD23', 'QQD31-QQD33',
'QQD51-QQD55', 'QQD61-QQD63', 'QQG11-QQG15', 'QQG21-QQG23',
'QQG31-QQG33', 'QQG41-QQG45', 'QQG51-QQG55', 'QQG61-QQG63',
'QQS21-QQS23', 'QQS31-QQS33', 'QQS51-QQS55', 'QQS61-QQS63'.
TOT-CHGS-HLD
____________
This field is accumulated for each Revenue Center Code on the
claim. It is calculated as follows:
- When the Revenue Center Code is equal to '0001', the
Inpatient financial charges are added to TOT-CHGS-HLD.
TOTAL DATE PROCESS
__________________
When the HLD-JUL-DTE9 work area is equal to '00000', or less than
'66001', or greater than '16366', zeros are moved to the 0DATE
work area, and the routine is exited. Otherwise, '66' is
subtracted from the YR (year-defined in the YR-CON table shown
below) giving a YR-DIF (year difference) work area. The ODATE is
computed by multiplying YR-DIF by '365' and adding the DY (days)
work area.
When the YR is equal to '66', exit the routine. Otherwise, add
the YR-FAC (defined in the YR-CON table in working storage)
subscripted by the YR-DIF work area to the ODATE.
Back in the calling routine, ODATE is moved to the appropriate
TOT-* field.
YR-CON Table
------------
01 YR-CON SYNC.
05 FILLER VALUE 00 PIC 99.
05 FILLER VALUE 00 PIC 99.
05 FILLER VALUE 01 PIC 99.
05 FILLER VALUE 01 PIC 99.
05 FILLER VALUE 01 PIC 99.
05 FILLER VALUE 01 PIC 99.
57
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
05 FILLER VALUE 02 PIC 99.
05 FILLER VALUE 02 PIC 99.
05 FILLER VALUE 02 PIC 99.
05 FILLER VALUE 02 PIC 99.
05 FILLER VALUE 03 PIC 99.
05 FILLER VALUE 03 PIC 99.
05 FILLER VALUE 03 PIC 99.
05 FILLER VALUE 03 PIC 99.
05 FILLER VALUE 04 PIC 99.
05 FILLER VALUE 04 PIC 99.
05 FILLER VALUE 04 PIC 99.
05 FILLER VALUE 04 PIC 99.
05 FILLER VALUE 05 PIC 99.
05 FILLER VALUE 05 PIC 99.
05 FILLER VALUE 05 PIC 99.
05 FILLER VALUE 05 PIC 99.
05 FILLER VALUE 06 PIC 99.
05 FILLER VALUE 06 PIC 99.
05 FILLER VALUE 06 PIC 99.
05 FILLER VALUE 06 PIC 99.
05 FILLER VALUE 07 PIC 99.
05 FILLER VALUE 07 PIC 99.
05 FILLER VALUE 07 PIC 99.
05 FILLER VALUE 07 PIC 99.
05 FILLER VALUE 08 PIC 99.
05 FILLER VALUE 08 PIC 99.
05 FILLER VALUE 08 PIC 99.
58
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
*Year 2000 is represented below.
05 FILLER VALUE 08 PIC 99.
05 FILLER VALUE 09 PIC 99.
05 FILLER VALUE 09 PIC 99.
05 FILLER VALUE 09 PIC 99.
05 FILLER VALUE 09 PIC 99.
05 FILLER VALUE 10 PIC 99.
05 FILLER VALUE 10 PIC 99.
05 FILLER VALUE 10 PIC 99.
05 FILLER VALUE 10 PIC 99.
05 FILLER VALUE 11 PIC 99.
05 FILLER VALUE 11 PIC 99.
05 FILLER VALUE 11 PIC 99.
05 FILLER VALUE 11 PIC 99.
05 FILLER VALUE 12 PIC 99.
05 FILLER VALUE 12 PIC 99.
05 FILLER VALUE 12 PIC 99.
05 FILLER VALUE 12 PIC 99.
*Year 2016 is represented above
01 YR-CON2 REDEFINES YR-CON.
05 YR-FAC OCCURS 50 TIMES PIC 99.
TRLR-SUB is a table index for the Beneficiary Part B trailer
table. It is set as follows:
- When the claim from year matches a Part B year on the
trailer table, TRLR-SUB points to the table entry in which
the match was found.
- When a Part B year on the trailer table is equal to the
default value, TRLR-SUB points to this table entry.
- When neither of the above is true, TRLR-SUB is equal to the
number of entries in the Part B trailer table plus '1'.
TRLR-SUB1 is a table index for the Beneficiary Part B trailer
table equal to TRLR-SUB minus 1.
UTILIZATION DAYS CALCULATIONS
_____________________________
Logic path to establish the utilization days calculations:
NOTE: The WS-BYPASS-HUIPUNCD is set to 'Y' when the following
error code conditions are present: '28#1', '33#1', '28#D',
'28#0'.
- When the stay from year is less than '89', and the stay thru
year is greater than '89', '90001' is moved to the HLD-JUL-
DTE9 work area.
- Otherwise, the stay Thru Date is moved to the HLD-JUL-DTE9
work area, and '001' is moved to DY when the stay from year
59
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
is not equal to the stay thru year. Based on either
'90001', or the stay Thru Date, a "perform" is done to TOT-
DTE to get the total days since 01/01/1966 for the TOT-
INTERIM-DTE field.
- When the patient status is not equal to '2', '3', '5', or
'30', and the Admission Date is equal to the stay Thru Date,
'1' is added to the TOT-INTERIM-DTE.
- The FULL-DAYS work area is computed by taking the Inpatient
utilization days minus the first-year coinsurance days minus
the second-year coinsurance days minus the total lifetime
reserve days.
- The FIRST-YEAR-DAYS work area is computed by taking the TOT-
INTERIM-DTE minus the TOT-FRM-DTE.
- When the stay from year is equal to the stay thru year, zero
is moved to the SEC-YEAR-DAYS, and when the patient status
is equal to '30', '1' is added to the FIRST-YEAR-DAYS.
- When the stay from year is not equal to the stay thru year,
the SEC-YEAR-DAYS work area is computed by subtracting the
TOT-INTERIM-DTE from the TOT-TRU-DTE, and when the patient
status is equal to '30', '1' is added to the SEC-YEAR-DAYS.
- When the BYPASS-HUIPUNCD switch is set, zeros are moved to
the NCD-NON-COV-1ST-DAYS and the NCD-NON-COV-2ND-DAYS.
Otherwise, the routine to determine the NCD-NON-COV-1ST-DAYS
and the NCD-NON-COV-2ND-DAYS is performed. In this routine,
the HUIPUNCD program, which determines the total number of
non-covered days, is called.
- The UTIL-DAYS1 work area is computed by taking the FIRST-
YEAR-DAYS minus the NCD-NON-COV-1ST-DAYS.
- When the UTIL-DAYS1 is greater than the Inpatient
utilization days, the Inpatient utilization days are moved
to the UTIL-DAYS1 work area.
- When the UTIL-DAYS1 is less than zero, zero is moved to
UTIL-DAYS1.
- When the stay from year is less than the stay thru year, the
UTIL-DYS2 work area is computed by taking the SEC-YEAR-DAYS
minus the NCD-NON-COV-2ND-DAYS. When the UTIL-DYS2 work
area is greater than the Inpatient utilization days minus
the UTIL-DAYS1 work area, the UTIL-DYS2 work area is
computed by taking the Inpatient utilization days minus the
UTIL-DAYS1 work area.
- When the UTIL-DYS2 is less than zero, zero is moved to the
UTIL-DYS2 work area.
- The FULL-DAYS1 work area is computed by taking the UTIL-
60
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
DAYS1 work area minus, the first-year coinsurance days,
minus the LR-DAS1 work area.
- When the stay from year is less than the stay thru year, the
FULL-DAYS2 work area is computed by taking the FULL-DAYS
work area, minus the FULL-DAYS1 work area.
- When the FULL-DAYS2 is less than zero, zero is moved to the
FULL-DAYS2 work area.
HOSPITAL BILLS ONLY
- When the HUIN-SNF-IND is not equal to '2', and the stay thru
year is greater than '89', or the stay from year is equal to
the stay thru year, the UTIL-DAYS1 work area is computed by
taking the UTIL-DAYS1 work area, minus the CAT-HOSP-FULL-
DAYS. Also, the FULL-DAYS1 work area is computed by taking
the FULL-DAYS1 work area minus the CAT-HOSP-FULL-DAYS.
- When the HUIN-SNF-IND is not equal to '2', and the stay thru
year is not greater than '89', or the stay from year is not
equal to the stay thru year, the UTIL-DYS2 work area is
computed by taking the UTIL-DYS2 work area minus the CAT-
HOSP-FULL-DAYS. Also, the FULL-DAYS2 work area is computed
by taking the FULL-DAYS2 work area, minus the CAT-HOSP-FULL-
DAYS.
When the UTIL-DAYS1 is less than zero, move zero to UTIL-DAYS1.
When the FULL-DAYS1 is less than zero, move zero to FULL-DAYS1.
When the UTIL-DAYS2 is less than zero, move zero to UTIL-DAYS2.
When the FULL-DAYS2 is less than zero, move zero to FULL-DAYS2.
DETERMINE CAT-HOS-FULL-DAYS
When the BYPASS-HUIPUNCD switch is not set, the routine to
determine the CAT-HOSP-FULL-DAYS is performed. In this routine,
the HUIPUNCD program (which determines the total number of non-
covered days), is called and the NCD-CAT-89-DAYS data is moved to
CAT-HOSP-FULL-DAYS when the HUIN-SNF-IND is not equal to '2'.
Zero is moved to CAT-HOSP-FULL-DAYS if HUIN-SNF-IND is equal to
'2'.
VALID-ADD-YR
____________
This '88' level is true when the CMN Auxiliary Maintenance
Transaction medical necessity length is equal to '12' or '99'.
VALID-CAT
_________
This '88' level is true when the CMN Auxiliary maintenance
transaction DMEPOS category is equal to '1', '2', '3', '4', '5',
61
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Glossary of Terms 1/6/2008
________________________________________________________________________
'6', '7', '8', '9', or 'A'.
VALID-CAT5
__________
This '88' level is true when the CMN certified medical necessity
length is equal to '03', '12', or '99'.
VALID-CAT6
__________
This '88' level is true when the CMN certified medical necessity
length is equal to '01'-'99'.
VALID-DELV-CAT
______________
This '88' level is true when the CMN Auxiliary maintenance
transaction DMEPOS category is equal to '1'-'4'.
VALID-LENGTH
____________
This '88' level is true when the CMN Auxiliary maintenance
Transaction medical necessity length is equal to '00'-'99'.
VALID-MSP-CODE
______________
VALID-MSP-CODE is true when the Medicare Secondary Payer code is
equal to 'A' through 'I', 'L', 'M', or 'N'.
VALID-PPUMP-RENT
________________
This '88' level is true when the CMN certified medical necessity
length is equal to '01-15', or '99'.
VALID-SCRN-RSLT
_______________
This '88' level is true when the DME screen result indicator is
within the range of 'A-T'.
W-BLOOD-HCPCS-CODE
__________________
62
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Glossary of Terms 1/6/2008
________________________________________________________________________
This '88' level is true when the Procedure Code is equal to
'P9010', 'P9011', 'P9021', or 'P9022'.
W-BLOOD-TYPE
____________
This '88' level is true when the type service is equal to '0'.
WITHN-HMO
_________
NOTE: The program HIGETHMO is called to return the two HMO
segments that are closest to the claim date. The 'current'
HMO segment referenced below represents the more current of
the two HMO segments returned.
- When NON-PPS-CLAIM is true, or the first position of the
bill type is not equal to '2', and WS-CHOICES-ID or WS-ESRD-
MANAGE-CARE-ID is true, the HMO-PATH-SW is set to WITHN-HMO:
- When the claim From Date is greater than, or equal to, the
current HMO Effective Date, and the claim Thru Date is less
than, or equal to, the current HMO Termination Date.
- When the claim From Date is greater than, or equal to, the
HMO Effective Date, and the current HMO Termination Date is
equal to zero.
- When the claim From Date is greater than, or equal to, the
prior HMO Effective Date, and the claim Thru Date is less
than, or equal to, the prior HMO Termination Date.
- When NON-PPS-CLAIM is not true, and the first position of
the bill type equals two, and WS-CHOICES-ID or WS-ESRD-
MANAGE-CARE-ID is true, the HMO-PATH-SW is set to WITHN-HMO:
- When the claim Admit Date is greater than, or equal to, the
current HMO Effective Date, and the claim Admit Date is less
than, or equal to, the current HMO Termination Date.
- When the claim Admit Date is greater than, or equal to, the
HMO Effective Date, and the current HMO Termination Date is
equal to zero.
- When the claim Admit Date is greater than, or equal to, the
prior HMO Effective Date, and the claim Admit Date is less
than, or equal to, the prior HMO Termination Date.
- When NON-PPS-CLAIM is true, or the first position of the
bill type is equal to two, and WS-CHOICES-ID is not true,
and WS-ESRD-MANAGE-CARE-ID is not true, and the claim From
Date is greater than '86000', set the HMO-PATH-SW to WITHN-
HMO:
63
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
- When the claim From Date is greater than, or equal to, the
current HMO Effective Date, and the claim From Date is less
than or equal to the current HMO Termination Date
- When the claim From Date is greater than, or equal to, the
current HMO Effective Date, and the current HMO Termination
Date is equal to zero.
- When the claim From Date is greater than, or equal to, the
prior HMO Effective Date, and the claim From Date is less
than, or equal to, the prior HMO Termination Date.
- When the current HMO option is equal to 'C', the claim Thru
Date is greater than, or equal to, the current HMO Effective
Date, the claim Thru Date is less than, or equal to, the
current HMO Termination Date, or the claim From Date is less
than, or equal to, the current HMO Termination Date and the
claim Thru Date is greater than, or equal to, the current
HMO Termination Date, or the current HMO Termination Date is
zeros, and the claim Thru Date is greater than, or equal to,
the current HMO Effective Date.
- When the current HMO option is not equal to 'C', the prior
HMO option is equal to 'C', the claim Thru Date is greater
than, or equal to, the prior HMO Effective Date, the claim
Thru Date is less than, or equal to, the prior HMO
Termination Date, or the claim From Date is less than, or
equal to, the prior HMO Termination Date, and the claim Thru
Date is greater than, or equal to, the prior HMO Termination
Date, or the prior HMO Termination Date is zeros, and the
claim Thru Date is greater than, or equal to, the prior HMO
Effective Date.
- When NON-PPS-CLAIM is not true, and the first position of
the bill type is not equal to '2', WS-CHOICES-ID is not
true, WS-ESRD-MANAGE-CARE-ID is not true, and the claim From
Date is greater than '86000', set the HMO-PATH-SW to WITHN-
HMO:
- When the claim Admit Date is greater than, or equal to, the
current HMO Effective Date, and the claim Admit Date is less
than or equal to the current HMO Termination Date.
- When the claim Admit Date is greater than, or equal to, the
current HMO Effective Date, and the current HMO Termination
Date is equal to zero.
- When the claim Admit Date is greater than, or equal to, the
prior HMO Effective Date, and the claim Admit Date is less
than, or equal to, the prior HMO Termination Date.
- When WS-CHOICES-ID, and WS-ESRD-MANAGE-CARE-ID is not true,
the first position of the bill type is not equal to two, and
the claim From Date is less than '86000', set the HMO-PATH-
64
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
SW to WITHN-HMO:
- When the claim From Date is greater than, or equal to, the
current HMO Effective Date, and the current HMO Termination
Date is equal to zero.
- When the claim From Date is greater than, or equal to, the
current HMO Effective Date, and the claim Thru Date is less
than, or equal to, the current HMO Termination Date.
- When the claim From Date is greater than or equal to the
current HMO Effective Date, the claim Thru Date is greater
than the current HMO Termination Date, the claim utilization
days are equal to '0', or the claim From Date plus claim
utilization days minus '1' is less than, or equal to, the
Part A entitlement Termination Date.
- When the claim From Date is greater than, or equal to, the
prior HMO Effective Date, and the claim Thru Date is less
than, or equal to, the prior HMO Termination Date.
- When the claim From Date is greater than, or equal to, the
prior HMO Effective Date, the claim Thru Date is greater
than the prior HMO Termination Date, the claim utilization
days are equal to '0', or the claim From Date plus claim
utilization days minus '1' is less than, or equal to, the
Part A entitlement Termination Date.
- When the claim From Date is greater than, or equal to, the
prior HMO Effective Date, and the claim Thru Date is greater
than the prior HMO Termination Date, and the claim
utilization days are not equal to '0', or the claim non-
utilization days are equal to '0', or the claim From Date
plus claim utilization days minus '1' is less than, or equal
to, the Part A entitlement Termination Date, and the 25th
occurrence of the claim data indicator is greater than, or
equal to, two.
W-KIDNEY-DONOR
______________
This '88' level is true when the type service is equal to 'N'.
WK-PSY-DED
__________
WK-PSY-DED is calculated by multiplying the Part B total
psychiatric charges subject to deductible by '.625'.
WORK-PSYCH-EXP-REMAIN
_____________________
65
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
This field is calculated as follows:
- When the claim stay From Date is greater than '88366', set
WORK-PSYCH-EXP-REMAIN equal to '2200.00' minus HLD-PSY-EXP.
- When the claim stay From Date is not greater than '88366',
and greater than '87365', set WORK-PSYCH-EXP-REMAIN equal to
'900.00' minus HLD-PSY-EXP.
- When the claim stay From Date is not greater than '87365',
set WORK-PSYCH-EXP-REMAIN equal to '500.00' minus HLD-PSY-
EXP.
- When WORK-PSYCH-EXP-REMAIN computes to a value that is less
than zero, set WORK-PSYCH-EXP-REMAIN to zero.
WORK-RICR-PSYCH-REMAIN
______________________
This field is calculated as follows:
- When the claim stay From Date is greater than '88366', set
WORK-RICR-PSYCH-REMAIN = '1375.00' minus HLD-RICR-PSY.
- When the claim stay From Date is greater than '87365', and
less than '88366', set WORK-RICR-PSYCH-REMAIN = '562.50'
minus HLD-RICR-PSY.
- When the claim stay From Date is not greater than '87365',
set WORK-RICR-PSYCH-REMAIN = '312.50' minus HLD-RICR-PSY.
- When WORK-RICR-PSYCH-REMAIN computes to a value that is less
than zero, set WORK-RICR-PSYCH-REMAIN to zero.
WS-AI-SKEL-HUBC
_______________
WS-AI-SKEL-HUBC is set to true when the CMN file is read and the
skeleton indicator is 'Y'.
WS-BENE-PARTB-ENTITLED-SW
_________________________
- S-BENE-PARTB-ENTITLED and S-BENE-NOT-PARTB-ENTITLED are '88'
levels of the same field, and are set as follows:
- S-BENE-PARTB-ENTITLED is initially set to true.
- When the Beneficiary Part B entitlement Start Date is equal
to zero, set S-BENE-NOT-PARTB-ENTITLED to true.
- When the claim stay From Date is greater than or equal to
the Beneficiary Part B entitlement Start Date, and the
66
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
Beneficiary Part B Termination Date is equal to zero, S-
BENE-PARTB-ENTITLED stays set to true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary Part B entitlement Start Date, and the
Beneficiary Part B Termination Date does not equal zero, and
the claim stay From Date is greater than the Beneficiary
Part B Termination Date, set S-BENE-NOT-PARTB-ENTITLED to
true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary Part B entitlement Start Date, the
Beneficiary Part B Termination Date does not equal zero, the
claim stay From Date is less than, or equal to, the
Beneficiary Part B Termination Date, and the claim stay Thru
Date is greater than the Beneficiary Part B Termination
Date, set S-BENE-NOT-PARTB-ENTITLED to true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary Part B entitlement Start Date, the
Beneficiary Part B Termination Date does not equal zero, the
claim stay From Date is less than, or equal to, the
Beneficiary Part B Termination Date, and the claim stay Thru
Date is not greater than the Beneficiary Part B Termination
Date, S-BENE-PARTB-ENTITLED stays set to true.
- When the Beneficiary prior Part B entitlement date is equal
to zero, set S-BENE-NOT-PARTB-ENTITLED to true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary prior Part B entitlement date, and the claim
stay From Date is greater than the Beneficiary prior Part B
Termination Date, set S-BENE-NOT-PARTB-ENTITLED to true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary prior Part B entitlement date, the claim
stay From Date is not greater than the Beneficiary prior
Part B Termination Date, and the claim stay Thru Date is
greater than the Beneficiary prior Part B Termination Date,
set S-BENE-NOT-PARTB-ENTITLED to true.
- When the claim stay From Date is greater than, or equal to,
the Beneficiary prior Part B entitlement date, the claim
stay From Date is not greater than the Beneficiary prior
Part B Termination Date, the claim stay Thru Date is not
greater than the Beneficiary prior Part B Termination Date,
S-BENE-PARTB-ENTITLED stays set to true.
- When none of the above conditions exists, set S-BENE-NOT-
PARTB-ENTITLED to true.
WS-BENE-MAMM-DATE
_________________
05 WS-BENE-MAMM-DATE.
67
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
10 WS-BENE-MAMM-MONTH PIC 9(02) VALUE ZEROS.
10 WS-BENE-MAMM-YEAR PIC 9(02) VALUE ZEROS.
Refer to the glossary for details on how the GLOBAL-BILL-SW,
TECHNICAL-BILL-SW, and PROFESSIONAL-BILL-SW are set.
For Part B claims:
- When the transaction ID is equal to 'HUBC', 'HBBC', or
'HIBC', GLOBAL-BILL-SW is equal to 'Y', or TECHNICAL-BILL-SW
is equal to 'Y', and the Beneficiary mammography technical
component date (sub) is not equal to '0', move the
Beneficiary technical component date (sub) to WS-BENE-MAMM-
DATE.
- When the transaction ID is equal to 'HUBC', 'HBBC', or
'HIBC', GLOBAL-BILL-SW is not equal to 'Y', and TECHNICAL-
BILL-SW is not equal to 'Y', and PROFESSIONAL-BILL-SW is
equal to 'Y', and the Beneficiary mammography professional
component date (sub) is not equal to '0', move the
Beneficiary professional component date (sub) to WS-BENE-
MAMM-DATE.
For Outpatient claims:
- When the transaction ID does is not equal to 'HUBC', 'HBBC',
or 'HIBC', and the Beneficiary mammography technical
component date (sub) is not equal to '0', move the
Beneficiary mammography technical component date (sub) to
WS-BENE-MAMM-DATE.
WS-BILL-TYPE-HOSPICE-NOE
________________________
This '88' level is true when the third position of the claim bill
type is equal to 'A', 'B', 'C', 'D', or 'E'.
WS-BILL-TYPE-NOE-CHANGE-OWNER
_____________________________
This '88' level is true when the third position of the claim bill
type is equal to 'E'.
WS-BILL-TYPE-NOE-CHANGE-PROV
____________________________
This '88' level is true when the third position of the claim bill
type is equal to 'C'.
WS-BILL-TYPE-NOE-REVOKE
_______________________
This '88' level is true when the third position of the claim bill
68
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
type is equal to 'B'.
WS-CASH-DEDUCT-AMT
__________________
This field is calculated as follows:
- When the claim Action Code is equal to '7', and the claim
Value Code is equal to 'A1', 'B1', or 'C1', move the claim
Value Code amount to WS-CASH-DEDUCT-AMT .
- When the claim Action Code is equal to '4' or '6', and not
CLAIM-IS-HOME-HEALTH, move the history cash deductible
amount to WS-CASH-DEDUCT-AMT.
- TRLR-SUB1 is a table index for the Beneficiary Part B
trailer table equal to TRLR-SUB minus 1.
When WS-CASH-DEDUCT-AMT is not greater than zero, the claim
Action Code is equal to '7', and the claim from year is less
than the Beneficiary Part B year (TRLR-SUB1) on the trailer
table, or less than the Beneficiary Part B fifth year, set
BENE-SW to 'P'.
- When WS-CASH-DEDUCT-AMT is greater than zero, the claim from
year does not match a Part B year on the trailer table, and
the claim from year is less than the Beneficiary Part B
fifth year, set BENE-SW to 'P'.
- When WS-CASH-DEDUCT-AMT is greater than zero, the claim from
year does not match a Part B year on the trailer table, the
claim from year is not less than the Beneficiary Part B
fifth year, the claim Action Code is equal to '7', and the
Beneficiary Part B fifth year is equal to the default value,
and the claim from year is not less than the Beneficiary
Part B year (TRLR-SUB1) on the trailer table, and the
Beneficiary Part B year (1) is not equal to the default
value, set BENE-SW to 'P'.
WS-C-NON-CAT-59
_______________
This '88' level is true when claim Procedure Code is equal to
'E0452', 'E0600', 'E0601', 'E0570', 'E0585', 'E1050', 'E1060',
'E1070', 'E1083', 'E1084', 'E1085', 'E1086', 'E1087', 'E1088',
'E1089', 'E1090', 'E1091', 'E1092', 'E1093', 'E1100', 'E1110',
'E1130', 'E1140', 'E1150', 'E1170', 'E1171', 'E1172', 'E1180',
'E1190', 'E1195', 'E1200', 'E1221', 'E1222', 'E1223', 'E1224',
'E1229', 'E1230', 'E1231', 'E1232', 'E1233', 'E1234', 'E1235',
'E1236', 'E1237', 'E1238', 'E1239', 'E1240', 'E1250', 'E1260',
'E1270', 'E1280', 'E1285', 'E1290', 'E1295', 'K0001', 'K0002',
'K0003', 'K0004', 'K0005', 'K0006', 'K0007', 'K0009', 'K0010',
'K0011', 'K0012', 'K0014', 'E0973', 'E0983', 'E0984', 'E0990',
'E1226', 'K0017', 'K0018', 'K0020', 'K0046', 'K0047', 'K0053'
69
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
or 'K0195'
WS-C-SHOE-HCPCS-ANY
___________________
This '88' level is true the when claim Procedure Code is equal to
'Q0117', 'Q0118', 'Q0119', 'Q0120', 'Q0121', 'Q0122', 'Q0123',
'Q0133', 'A5500', 'A5501', 'A5502', 'A5503', 'A5504', 'A5505',
'A5506', 'A5507', or 'L3649'.
WS-CHOICES-ID
_____________
The following HMO numbers are valid CHOICES HMOs:
'H0516', 'H0565', 'H1021', 'H1096', 'H1163', 'H1165', 'H1169',
'H2551', 'H2749', 'H3669', 'H3965', 'H3966', 'H4463', 'H4572',
'H4577'
WS-CLAIM-COMPARE-DATE
_____________________
05 WS-CLAIM-COMPARE-DATE.
10 WS-CLAIM-COMPARE-YEAR PIC 9(02) VALUE ZEROS.
10 WS-CLAIM-COMPARE-MONTH PIC 9(02) VALUE ZEROS.
The WS-CLAIM-COMPARE-DATE is populated by the conversion of the
WS-CLAIM-DATE-OF-SERVICE from Julian to the calendar year/month
format.
WS-CLAIM-DATE-OF-SERVICE
________________________
For Part B claims:
- When transaction ID is equal to 'HUBC', 'HBBC', or 'HIBC',
the claim Thru Date or the history Thru Date is passed to
the mammography module and is moved to WS-CLAIM-DATE-OF-
SERVICE.
NOTE: When determining whether to move the history date, each line
item on the history claim is examined. These fields will be
referenced by CSUB.
- When the claim Entry Code is equal to a '3' or '5', and the
history CMS service type (CSUB) is equal to 'B' or 'C', the
history First-Expense date is greater than '91000', the
history Procedure Code (CSUB) is equal to '76092', and the
history Sex Code is equal to '2', the history Thru Date is
passed to the mammography module.
When the above statement is not true, the claim Thru Date is
70
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
passed to the mammography module.
For Outpatient claims:
- When transaction ID is equal to 'HUOP', 'HBOP', or 'HIOP',
WS-CLAIM-DATE-OF-SERVICE is populated as follows:
- The Span Code table of '10' entries is searched. When the
occurrence Span Code is equal to '72', the occurrence span
From Date matching that entry is moved to the WS-CLAIM-DATE-
OF-SERVICE.
- When there is no Span Code equal to '72' found, the claim
Thru Date is moved to WS-CLAIM-DATE-OF-SERVICE.
WS-CLAIM-MAMM-DATE
__________________
05 WS-CLAIM-MAMM-DATE.
10 WS-CLAIM-MAMM-MONTH PIC 9(02) VALUE ZEROS.
10 WS-CLAIM-MAMM-YEAR PIC 9(02) VALUE ZEROS.
Note: Refer to the glossary for details on how the WS-CLAIM-DATE-
OF-SERVICE is populated.
The WS-CLAIM-MAMM-DATE is populated by the conversion of the WS-
CLAIM-DATE-OF-SERVICE from Julian to the calendar month/year
format.
WS-DATE-EFF-ERR
_______________
This switch is initialized to 'N'.
It is set to 'Y' when any of the following conditions are true:
- When the MSP Effective Date is not numeric.
- When the MSP Effective Date century is not equal to '19' or
'20'.
- When the MSP Effective Date is greater than the MSP
Termination Date.
- When the MSP Effective Date is equal to zero, and the MSP
Payer Code is not equal to 'A', 'B', 'D', 'E', 'F', 'G',
'H', 'I', or 'L'.
- When the MSP Effective Date is less than the valid date for
the MSP Code.
MSP Code Valid Date
A 1983 01 01
B 1981 10 01
71
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
D 1980 12 01
E 1966 07 01
F 1966 07 01
I 1966 07 01
H 1973 07 01
G 1987 01 01
L 1980 12 01
- When the calculated date that the Beneficiary becomes 65
years old is numeric, and greater than zero, and when one of
the following is true:
- The MSP Code is not equal to 'B' or 'G'.
OR
- The MSP Effective Date is not less than the calculated date
that the Beneficiary becomes 65 years old, and the MSP Code
is equal to 'G'.
WS-ERROR-SW
___________
WS-ERROR-SW is a switch used to indicate that an error has or has
not occurred, WS-ERROR-SW is initialized to 'N' and when an error
occurs, WS-ERROR-SW will equal 'Y' .
WS-ESRD-MANAGE-CARE-ID
______________________
The following HMO numbers are valid ESRD Managed Care IDs:
'H0565' and 'H1021'.
WS-ESRD-NGDATA
______________
This '88' level is true when the value of WS-ESRD-SW is equal to
'I'.
WS-ESRD-SW is initialized to 'I' prior to reading the ESRD
Auxiliary file. When CMN Auxiliary maintenance transaction
initial Certification date is not less than the ESRD Auxiliary
file ESRD select date ('1', '2', or '3'), the WS-ESRD-SW is set to
'V'.
WS-HOLD-FROM-DATE
_________________
This field is used to reference the Outpatient claim service From
Date, or if present, the Span Code '72' From Date ('24' - and '72'
- hour edits).
72
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
WS-HOLD-THRU-DATE
_________________
This field is used to reference the Outpatient claim service Thru
Date, or if present, the Span Code '72' Thru Date ('24' - and '72'
- hour edits).
WS-HO-PROCESS-SW
________________
WS-HO-PROCESS-SW is set as follows:
- WS-HO-PROCESS-SW is used in the logic flow that creates the
new Hospice period trailers. SUBH1 is the index for the new
claim Hospice Table, pointing to the most recent entitlement
period, where the first Start Date for the period is less
than, or equal to, the claim From Date. SUBH2 is a table
index equal to SUBH1 plus '1'.
- When an error code is set anytime during the execution of
logic to create the new Hospice period trailers, set WS-HO-
PROCESS-SW to '3'.
- When the From Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, or the
claim Hospice Table index (SUBH1) is equal to '4', and the
Hospice Revocation Indicator (SUBH1) is equal to '0', set
WS-HO-PROCESS-SW to '0'.
- When the From Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, or the
claim Hospice Table index (SUBH1) is equal to '4', the
Hospice Revocation Indicator (SUBH1) is equal to '0', the
claim Hospice Table index, SUBH1 is equal to '4', and the
Hospice Revocation Indicator (SUBH1) is equal to '0', set
WS-HO-PROCESS-SW to '1'.
- When the From Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, or the
claim Hospice Table index (SUBH1) is equal to '4', Hospice
Revocation Indicator (SUBH1) is equal to '0', the claim
Hospice Table index, SUBH1, is equal to '3', the Hospice
Revocation Indicator (SUBH1) is equal to '0', or the Hospice
Termination Date (SUBH1) is greater than, or equal to,
'90000', the Hospice Termination Date (SUBH1) is greater
than '89000', and the claim Hospice Table index (SUBH1), is
greater than, or equal to, the Hospice trailer counter, set
WS-HO-PROCESS-SW to '1'.
- When the From Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, or the
claim Hospice Table index (SUBH1) is equal to '4', the
Hospice Revocation Indicator (SUBH1) is equal to '0', the
Hospice Table index (SUBH1) is equal to '1' or '2', the
Hospice Revocation Indicator (SUBH1) is equal to '0', and
73
Common Working File - Appendices SYSDEF
Glossary of Terms 1/6/2008
________________________________________________________________________
the From Date on the Hospice claim is less than, or equal
to, the Hospice Termination Date (SUBH1), set WS-HO-PROCESS-
SW to '2'.
- When the From Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, or the
claim Hospice Table index (SUBH1) is equal to '4', and WS-
HO-PROCESS-SW is not equal to '2' or '3', set WS-HO-PROCESS-
SW to '0'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, set WS-
HO-PROCESS-SW to '0'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), and the Termination Date (SUBH1)
is less than '89000', set WS-HO-PROCESS-SW to '2'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), and the claim Hospice Table index,
SUBH1, is less than the Hospice trailer counter, set WS-HO-
PROCESS-SW to '2'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), and the Hospice Table index,
SUBH1, is equal to '4', and the Hospice Revocation Indicator
(SUBH1) is equal to '0', set WS-HO-PROCESS-SW to '1'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1) on the claim Hospice Table, and the
Hospice Table index, SUBH1, is equal to '3', and the Hospice
Revocation Indicator (SUBH1) is equal to '0', set WS-HO-
PROCESS-SW to '1'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), the Hospice Revocation Indicator
(SUBH1) is equal to '0', and the Thru Date on the Hospice
claim is less than, or equal to, the calculated Termination
Date for the new Hospice period (SUBH2), set WS-HO-PROCESS-
SW to '1'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), WS-HO-PROCESS-SW is equal to '2',
the Hospice Table index, SUBH1, is less than the Hospice
trailer counter, the calculated Termination Date for the new
Hospice period is equal to the first Provider Start Date for
the new Hospice period (SUBH2), the Thru Date on the claim
is less than, or equal to, the Termination Date for the new
Hospice period (SUBH2), and the Hospice Table index SUBH2 is
equal to '4', and the Thru Date on the claim is greater than
the date of last billing activity for the new Hospice period
(SUBH2), set WS-HO-PROCESS-SW to '1'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), WS-HO-PROCESS-SW is equal to '2',
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the Hospice Table index, SUBH1, is less than the Hospice
trailer counter, the calculated Termination Date for the new
Hospice period is equal to the first Provider Start Date for
the new Hospice period (SUBH2), the Thru Date on the claim
is less than, or equal to, the Termination Date for the new
Hospice period (SUBH2), and the Hospice Table index (SUBH2)
is not equal to '4', or the Thru Date on the claim is less
than, or equal to, the date of last billing activity for the
new Hospice period (SUBH2), set WS-HO-PROCESS-SW to '1'.
- When the Thru Date on the Hospice claim is greater than the
Termination Date (SUBH1), and WS-HO-PROCESS-SW is not equal
to '3', set WS-HO-PROCESS-SW to '0'.
- When the From Date on the Hospice claim is less than or
equal to the Termination Date (SUBH1) on the claim Hospice
Table, and the Thru Date on the Hospice claim is less than,
or equal to, the Termination Date (SUBH1) on the claim
Hospice Table, set WS-HO-PROCESS-SW to '0'.
WS-INIT-ERR-IND
When the CMN Certification Date is 60 days greater than the
current date, set WS-INIT-ERR-IND to 'Y'
WS-IX
_____
WS-IX is an indicator that is initialized to 'N' and set to 'Y'
when any of the following conditions are true:
- When the CMN Auxiliary maintenance transaction Contractor
number is equal to the CMN Auxiliary file original DMERC
- When the CMN Auxiliary maintenance transaction
Recertification Date is equal to the CMN Auxiliary file
Recertification Date
- When the CMN Auxiliary maintenance transaction initial
Certification Date is equal to the CMN Auxiliary file
initial Certification Date.
WS-ERR-IND
__________
WS-ERR-IND is an indicator that is initialized to 'No'. This
switch should be turned on if a 'C107', 'C109', or 'C110' error is
found, indicating that an error has already set, and another error
code should not set.
WS-MAMMOGRAPHY-CLAIM-SW
_______________________
When the transaction ID is 'HUOP', 'HBOP', or 'HIOP':
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- When the first two positions of the bill type are equal to
'14', '22', '23', '73', or '85',
OR
- RHC-MAMMO-71X-BILL:
- When there is a claim line with a Revenue Code equal to
'0403' and the HCPCS code on the line equals '76092', move
'1' to WS-MAMMOGRAPHY-CLAIM-SW.
WS-MOD1-Q3
__________
This '88' level is true when the Procedure Code Modifier '1' is
equal to 'Q3'.
WS-MOD2-Q3
__________
This '88' level is true when the Procedure Code Modifier 2 is
equal to 'Q3'.
WS-MSP-AMT-APPLIED
__________________
- WS-MSP-AMT-APPLIED is calculated as follows:
- When WS-CHOICES-ID or WS-ESRD-MANAGE-CARE-ID, WS-MSP-AMT-
APPLIED is '0'.
- When not WS-CHOICES-ID, WS-MSP-AMT-APPLIED is the total
accumulation of the Medicare as Secondary Payer applied
amounts of each line item.
WS-MSP-TYPE-CODE
________________
WS-MSP-TYPE-CODE is set as follows:
- For Part B/DME:
When the claim line item Pay Process Indicator equals
'Q', 'T', 'U', 'V', or 'Y', move the claim line item
Pay Process Indicator to WS-MSP-TYPE-CODE.
- When the claim line item Pay Process Indicator does
not equal 'Q', 'T', 'U', 'V', or 'Y', and the claim
line item Pay Process Indicator is equal to 'X', move
'X' to WS-MSP-TYPE-CODE.
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- When the claim line item Pay Process Indicator does
not equal 'Q', 'T', 'U', 'V', or 'Y', and the claim
line item Pay Process Indicator does not equal 'X',
move the claim MSP payer flag to WS-MSP-TYPE-CODE.
- For Inpatient:
- When the claim line item Value Code equals '12', and
the claim line item value amount is greater than '0',
move 'A' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '12', and
the claim line item value amount is equal to '0', move
'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '13', and
the claim line item value amount is greater than '0',
move 'B' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '13', and
the claim line item value amount is equal to '0', move
'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '14', and
the claim line item value amount is greater than '0',
move 'D' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '14', and
the claim line item value amount is equal to '0', move
'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '15', and
the claim line item value amount is greater than '0',
move 'E' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '15', and
the claim line item value amount is equal to '0', move
'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '16', and
the claim line item value amount is greater than '0',
move 'F' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '16', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '41', and
the claim line item value amount is greater than '0',
move 'H' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '41', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '42', and
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the claim line item value amount is greater than '0',
move 'I' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '42', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '43', and
the claim line item value amount is greater than '0',
move 'G' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '43', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '47', and
the claim line item value amount is greater than '0',
move 'L' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '47', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Revenue Code is equal to
'0001', and the claim line item Financial or Revenue
Override Code is equal to 'M', move 'M' to WS-MSP-
TYPE-CODE.
- When the claim line item Revenue Code is equal to
'0001', and the claim line item Financial or Revenue
Override Code is equal to 'N', move 'N' to WS-MSP-
TYPE-CODE.
- When the WS-MSP-TYPE-CODE is equal to spaces, and the
claim Non-Payment Code is equal to 'E', 'F', 'G', 'H',
'J', 'K', 'Q', 'T', 'U', 'V', 'Y', or 'X', move the
claim non-payment code to WS-MSP-TYPE-CODE.
- For Outpatient:
- When the claim line item Value Code equals '12', and
the claim line item value amount is greater than '0',
move 'A' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '12', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '13', and
the claim line item value amount is greater than '0',
move 'B' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '13', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
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- When the claim line item Value Code equals '14', and
the claim line item value amount is greater than '0',
move 'D' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '14', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '15', and
the claim line item value amount is greater than '0',
move 'E' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '15', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '16', and
the claim line item value amount is greater than '0',
move 'F' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '16', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '41', and
the claim line item value amount is greater than '0',
move 'H' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '41', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '42', and
the claim line item value amount is greater than '0',
move 'I' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '42', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '43', and
the claim line item value amount is greater than '0',
move 'G' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '43', and
the claim line item value amount is not greater than
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '47', and
the claim line item value amount is greater than '0',
move 'L' to WS-MSP-TYPE-CODE.
- When the claim line item Value Code equals '47', and
the claim line item value amount is not greater than
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________________________________________________________________________
'0', move 'C' to WS-MSP-TYPE-CODE.
- When the claim line item Revenue Code is equal to
'0001', and the claim line item Financial or Revenue
Override Code is equal to 'M', move 'M' to WS-MSP-
TYPE-CODE.
- When the claim line item Revenue Code is equal to
'0001', and the claim line item Financial or Revenue
Override Code is equal to 'N', move 'N' to WS-MSP-
TYPE-CODE.
WS-NDX-AI
_________
This indicator is set when an active (non-logically deleted) CMN
Initial Certification Record is not found.
WS-NDX-AR
_________
WS-NDX-AR is a counter that is used to search through CMN
Auxiliary data.
This counter is initialized to '1' and incremented by '1'.
This counter is also initialized to '1' and set to a '-1' as
follows:
- When WS-NDX-AR is greater than the CMN number of re-
certifications.
WS-NULL-IND
WS-NULL-IND is set to true as follows:
WS-NULL-IND is initialized to 'N'.
When the CMN Scheduled Recertification Date is equal to
spaces, low values, or zeros, and CMN-T-CERT-INIT is true,
and the CMN DMEPOS Category '5' is true, and the CMN
certified medical necessity length is equal to '99', set WS-
NULL-IND to 'Y'.
When the CMN Scheduled Recertification Date is equal to
spaces, low values, or zeros, and CMN-T-CERT-INIT is true,
and the CMN DMEPOS Category '5' is not true, set WS-NULL-IND
to 'Y'.
When the CMN Scheduled Recertification Date is equal to
spaces, low values, or zeros, and CMN-T-CERT-RECERT is true,
and the CMN DMEPOS Category '5' is true, and the CMN
certified medical necessity length is equal to '99', set WS-
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________________________________________________________________________
NULL-IND to 'Y'.
When the CMN scheduled Recertification Date is equal to
spaces, low values, or zeros, and CMN-T-CERT-REDCERT is
true, and the CMN DMEPOS Category '5' is not true, set WS-
NULL-IND to 'Y'.
When the CMN scheduled Recertification Date is equal to
spaces, low values, or zeros, and CMN-T-CERT-INIT is not
true and the CMN-T-CERT-RECERT is not true, set WS-NULL-IND
to 'Y'.
WS-PRE-ENT-PERIOD-SW
____________________
WS-PRE-ENT-PERIOD-SW is set as follows:
- When CA-SPELL-WK-CODE or CA-SEC-SPELL-WK-CODE is not equal
to '0', and the Date of Earliest Billing Activity for the
spell equals the Beneficiary Part A entitlement Start Date,
set the WS-PRE-ENT-PERIOD-SW switch to 'Y'.
WS-REL-CERT-TRM-DATE
____________________
This working storage area contains the Clinical Laboratory
Improvement Amendment (CLIA) certification Effective Date or the
Relative Date '65535', when the CLIA certification Effective Date
is zero.
WS-STATE-TABLE-VALUES
_____________________
Valid state codes used in the processing of Durable Medical
Equipment (DME) claims:
01 WS-STATE-TABLE-VALUES.
05 FILLER PIC X(02) VALUE 'AK'.
05 FILLER PIC X(02) VALUE 'AL'.
05 FILLER PIC X(02) VALUE 'AR'.
05 FILLER PIC X(02) VALUE 'AS'.
05 FILLER PIC X(02) VALUE 'AZ'.
05 FILLER PIC X(02) VALUE 'CA'.
05 FILLER PIC X(02) VALUE 'CO'.
05 FILLER PIC X(02) VALUE 'CT'.
05 FILLER PIC X(02) VALUE 'DC'.
05 FILLER PIC X(02) VALUE 'DE'.
05 FILLER PIC X(02) VALUE 'FC'.
05 FILLER PIC X(02) VALUE 'FL'.
05 FILLER PIC X(02) VALUE 'GA'.
05 FILLER PIC X(02) VALUE 'GU'.
05 FILLER PIC X(02) VALUE 'HI'.
05 FILLER PIC X(02) VALUE 'IA'.
05 FILLER PIC X(02) VALUE 'ID'.
05 FILLER PIC X(02) VALUE 'IL'.
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________________________________________________________________________
05 FILLER PIC X(02) VALUE 'IN'.
05 FILLER PIC X(02) VALUE 'KS'.
05 FILLER PIC X(02) VALUE 'KY'.
05 FILLER PIC X(02) VALUE 'LA'.
05 FILLER PIC X(02) VALUE 'MA'.
05 FILLER PIC X(02) VALUE 'MD'.
05 FILLER PIC X(02) VALUE 'ME'.
05 FILLER PIC X(02) VALUE 'MI'.
05 FILLER PIC X(02) VALUE 'MN'.
05 FILLER PIC X(02) VALUE 'MO'.
05 FILLER PIC X(02) VALUE 'MP'.
05 FILLER PIC X(02) VALUE 'MS'.
05 FILLER PIC X(02) VALUE 'MT'.
05 FILLER PIC X(02) VALUE 'NB'.
05 FILLER PIC X(02) VALUE 'NC'.
05 FILLER PIC X(02) VALUE 'ND'.
05 FILLER PIC X(02) VALUE 'NE'.
05 FILLER PIC X(02) VALUE 'NH'.
05 FILLER PIC X(02) VALUE 'NJ'.
05 FILLER PIC X(02) VALUE 'NM'.
05 FILLER PIC X(02) VALUE 'NV'.
05 FILLER PIC X(02) VALUE 'NY'.
05 FILLER PIC X(02) VALUE 'OH'.
05 FILLER PIC X(02) VALUE 'OK'.
05 FILLER PIC X(02) VALUE 'OR'.
05 FILLER PIC X(02) VALUE 'PA'.
05 FILLER PIC X(02) VALUE 'PR'.
05 FILLER PIC X(02) VALUE 'RI'.
05 FILLER PIC X(02) VALUE 'SC'.
05 FILLER PIC X(02) VALUE 'SD'.
05 FILLER PIC X(02) VALUE 'TN'.
05 FILLER PIC X(02) VALUE 'TX'.
05 FILLER PIC X(02) VALUE 'UT'.
05 FILLER PIC X(02) VALUE 'VA'.
05 FILLER PIC X(02) VALUE 'VI'.
05 FILLER PIC X(02) VALUE 'VT'.
05 FILLER PIC X(02) VALUE 'WA'.
05 FILLER PIC X(02) VALUE 'WI'.
05 FILLER PIC X(02) VALUE 'WV'.
05 FILLER PIC X(02) VALUE 'WY'.
WS-TOTAL-PSY-DAYS
_________________
WS-TOTAL-PSY-DAYS are set as follows:
- When the Inpatient pre-entitlement psychiatric days history
is greater than '0', WS-TOTAL-PSY-DAYS equals the sum of the
Inpatient pre-entitlement psychiatric days history, plus the
psychiatric days used in the benefit period, plus the
utilization days from the claim.
- When the Inpatient pre-entitlement psychiatric days history
is less than, or equal to, '0', WS-TOTAL-PSY-DAYS equals the
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________________________________________________________________________
sum of the Inpatient pre-entitlement psychiatric days on the
claim, plus the psychiatric days used in the benefit period,
plus the utilization days from the claim.
WSV-CERT-END
____________
This field is set as follows:
- Move the CMN Auxiliary maintenance transaction discontinued
Certification Date to WSV-CERT-END.
- If WSV-CERT-END is equal to zero, move +32767 to WSV-CERT-
END.
WS-VER-CSH-DED
______________
This field is calculated as follows:
- When a Value Code from the claim Value Code table is equal
to 'A1', 'B1', or 'C1', and the value amount for that Value
Code is numeric, set WS-VER-CSH-DED to the value amount.
- When one of the following is true:
- When WS-VER-CSH-DED is equal to zero, and HLD-DED-TBM
is not equal to zero,
OR
- When WS-VER-CSH-DED is not equal to zero, and WS-VER-
CSH-DED is less than HLD-DED-TBM,
AND
- When WS-VER-CSH-DED is not equal to the claim
deductible expenses, and the claim deductible expenses
are less than HLD-DED-TBM, move the claim deductible
expenses to WS-VER-CSH-DED.
- When one of the following is true:
- When WS-VER-CSH-DED is equal to zero, and HLD-DED-TBM
is not equal to zero,
OR
- When WS-VER-CSH-DED is not equal to zero, and WS-VER-
CSH-DED is less than HLD-DED-TBM,
AND
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________________________________________________________________________
- When WS-VER-CSH-DED is not equal to the claim
deductible expenses, and the claim deductible expenses
are less than HLD-DED-TBM, move HLD-DED-TBM to WS-VER-
CSH-DED.
- When WS-VER-CSH-DED is not equal to the claim
deductible expenses, and one of the following is true:
- When WS-VER-CSH-DED is equal to zero, and HLD-DED-TBM
is not equal to zero,
OR
- When WS-VER-CSH-DED is not equal to zero, and WS-VER-
CSH-DED is less than HLD-DED-TBM, set WS-VER-CSH-DED
to zero.
WS-YES-AI-OCC
_____________
WS-YES-AI-OCC is set to true when the Certificate of Medical
Necessity skeleton indicator is not true, HCPCS Edit Category '1',
'5', and '10' are false, and Procedure Code Modifier '1', '2',
'3', and '4' are not equal to maintenance service mod or repair
mod.
YEAR-MATCH-SW
_____________
The YEAR-MATCH-SW is set as follows:
- When the claim first-expense year is less than the current
year minus '4', move 'F' to YEAR-MATCH-SW.
- When the claim first-expense year is equal to any of the
first four history Part B year entries, move 'M' to YEAR-
MATCH-SW.
- When a match is not found in the first four history entries
on the Beneficiary Master Record, move 'N' to YEAR-MATCH-SW.
- When the claim first-expense year is greater than, or equal
to, the current year minus '4', and the claim first-expense
year equals the Beneficiary Part B year, move 'M' to YEAR-
MATCH-SW.
YEAR-SUB is a table index for the Beneficiary Part B trailer
table, varied from '1' to the number of entries in the table.
