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FISS/DDE Provider Online Guide: Chapter IV


Beneficiary/CWF (10)

Purpose

The purpose of the beneficiary screens is to provide access to all beneficiaries contained on the eligibility file. The provider can use this file to verify beneficiary data.

The first two screens of this option are Beneficiary Inquiry screens.

The remaining pages are CWF records. The CWF screens are highly recommended for verifying beneficiary data.

FISS Inquiry Submenu

To access the Beneficiary/CWF option from the FISS online Inquiries submenu, type ‘10’ at the Enter Menu Selection:prompt, then press the <Enter>key.

Upon selecting the Beneficiary/CWF Option, the Initial Eligibility Detail Inquiry Screen is available:

Eligibility Detail Inquiry Screen - To access beneficiary information, enter HIC, Last Name, First Initial, Sex code, Date of Birth

To view the Eligibility Detail housed within the Beneficiary/CWF option, key the beneficiary’s information in the following FISS fields and press the <Enter> key.

  • MID
  • LN (last name)
  • FI (first initial)
  • SEX (M – male; F – female)
  • DOB (date of birth)

After entering the beneficiary’s information, the FISS Eligibility Detail Screens are available:

Eligibility Detail Inquiry Screen - After entering beneficiary information, CWF returns entitlement data including dates of entitlement, termination, benefit period information, etc.

Field Description
MID Medicare ID number
CURR XREF HIC Current cross reference Medicare number – If the Medicare number has changed for the beneficiary/patient, this field represents the most recent number (as returned by CWF). The Medicare number entered in the HIC field has been changed to this Medicare number. If there is a Medicare number in this field, it is the number that should be used for billing.
PREV XREF HIC Not used in DDE
TRANSFER HIC Not used in DDE
C-IND Century indicator – Tells the system what century to use with the birth date to determine the beneficiary’s age. For example, if the beneficiary’s date of birth was reported as 01/21/88, and the century indicator was an ‘8,’ the age would be calculated based on 1888. If the century indicator is ‘9,’ then the age would be calculated based upon 1988.
LTRDAYS Lifetime reserve days remaining
LN Beneficiary last name
FN Beneficiary first name
MI Beneficiary middle initial
SEX Beneficiary sex
DOB Date of birth – Reported in MMDDYYYY format
DOD Date of death – If one has been received by CWF. Reported in MMDDYY format
ADDR Beneficiary street address
CITY Beneficiary city of residence
ST Beneficiary state of residence
ZIP Beneficiary ZIP Code

Current Entitlement

Field Description
PART A EFF DT Effective date of Part A current entitlement in MMDDYY format
TERM DT Termination Date Part A entitlement was terminated in MMDDYY format
PART B EFF DT Effective date of Part B current entitlement in MMDDYY format
TERM DT Termination Date Part B entitlement was terminated in MMDDYY format

Benefit Period Data

Field Description
FRST BILL DT Date of earliest billing action in MMDDYY format
LST BILL DT Date of latest billing action in MMDDYY format
HSP FULL DAYS Full inpatient hospital days remaining in current benefit period
HSPPART DAYS Inpatient hospital coinsurance days remaining in current benefit period
SNF FULL DAYS Full inpatient SNF days remaining in current benefit period
SNF PART DAYS Inpatient coinsurance SNF days remaining in current benefit period
INP DED REMAIN Inpatient deductible remaining to be met in the current benefit period
BLDDED PNTS Inpatient Part A blood deductible pints remaining to be met in the current benefit period

Psychiatric

Field Description
PSY DAYS REMAIN Number of lifetime psychiatric days remaining (based upon a maximum benefit of 190 days)
PRE PHY DAYS USED Number of pre-entitlement days used when the beneficiary was in a psychiatric hospital that reduce the number of regular days available to the beneficiary during their initial benefit period
PSY DIS DT Psychiatric discharge date – Last discharge date from a psychiatric hospital for this beneficiary in MMDDYY format
INTRM DT IND Interim date indicator – One-position indicator showing an interim date for psychiatric services

Valid values
Y = Date is through date of an interim bill; utilization day
N = Discharge date; not a utilization day

Use the <F8> key to move forward to FISS Eligibility Detail Screen 2.

Eligibility Detail Inquiry Screen #2 provides Part B and HMO data as well as hospice election period information

Field Description
RI CWF Inquiry Type
Valid value = 1 (CWF FISS Inquiry)
MAMMO DT Date of last mammogram in CCYYMMDD format

Part B Data

Field Description
SRV YR Reports the year to which the data applies, in YY format.
MEDICAL EXPENSE Amount applied to the Part B cash deductible for the service year.
BLD DED REM Number of pints remaining to be applied to the beneficiary’s calendar year blood deductible.
PSY EXP Psychiatric expense – Amount of reasonable charges applied toward the beneficiary’s yearly maximum.
SRV YR Reports the year to which the data applies.
BLD DED Field not used in DDE
CSH DED Field not used in DDE

Plan Data

Field Description
ID CD Plan Identification code of the HMO ‑ Five-position field defined as the following:

Position 1 = H (constant)
Position 2 and 3 = Two-digit state code
Position 4 and 5 = Two-digit code assigned to the HMO
OPT CD Option code for HMO which indicates whether the services are restricted or unrestricted.

Valid Values
1 = Unrestricted; intermediary to process all Part A and Part B provider claims
2 = Unrestricted; HMO to process claims for directly provided services and for services from providers with effective arrangements. Intermediary to process all other claims
A = Restricted; intermediary to process all Part A and Part B claims
B = Restricted; HMO to process claims only for directly provided services
C = Restricted; HMO to process all claims
EFF DT Effective date of a beneficiary’s HMO enrollment
CANC DT Termination date of a beneficiary’s HMO enrollment

Hospice Data

Field Description
PERIOD Hospice period – Identifies the specific hospice election period. Four different periods may be displayed, depending upon the number of election periods that the beneficiary may have already used. The valid values are 1, 2, 3 or 4.
1ST DT First start date – Displays the start date of beneficiary’s effective period with the first hospice provider that the beneficiary chose during the period.
PROVIDER Provider number – Identifies the number of the Medicare hospice provider.
INTER Intermediary number – Identifies the intermediary number for the hospice provider.
OWNER CHANGE ST DT Change of ownership start date – Displays the start date of a change of ownership for the first provider, within the period.
2ND ST DT Second start date – Displays start date of the beneficiary’s effective period with the second hospice provider that the beneficiary chose to use during period.
TERM DT Termination date – Displays the termination date of the beneficiary’s effective period.
OWNER CHANGE ST DT Change of ownership start date – Displays the start date of a change of ownership for the second provider, within the period.
1ST BILL DATE First date of service billed under the hospice election
LST BILL DATE Last date of service billed under the hospice election
DAYS BILLED Cumulative number of days billed to date for the beneficiary under the hospice election

Use the <F8> key to access CWF on the next page. CWF contains multiple pages of beneficiary eligibility data, starting with Preventive Services screens.

One way for Medicare beneficiaries to stay healthy is to use preventive services provided by doctors and health care providers. Preventive services can find health problems early when treatment works best. This information will display when the next eligible date is available for preventive services covered by Medicare for a given beneficiary.

All eligibility fields will report the next eligible date or a three- or four-position alpha code to indicate the reason why there is no eligibility date. Valid values include:

  • PTB – Beneficiary not entitled to Part B
  • RCVD – Beneficiary already received service
  • DOD – Beneficiary not eligible due to DOD
  • GDR – Beneficiary not eligible due to gender
  • AGE – Beneficiary not eligible due to age
  • SRV – Beneficiary not eligible for the service
  • VAC – Beneficiary already vaccinated
  • 0000 – Service not applicable

FISS manual update: Chapter IV: Beneficiary CWF (10) provides next eligible dates for each preventive service, also provides applicable HCPCS/CPT code

Field Description
MID Medicare ID number
NM Last name
IT First initial
DB Date of birth
SX Sex (M – male; F – female)
PRVN SERVC Category of one or more Preventive Service HCPCS/CPT procedure codes
TECH D Technical date – next date beneficiary is eligible to receive technical component of preventive service or indication code
PROF D Professional date – next date beneficiary is eligible to receive professional component of preventive service or indication code
CARD/80061 Screening for CVD HCPCS code 80061
CARD/82465 Screening for CVD HCPCS code 82465
CARD/83718 creening for CVD HCPCS code 83718
CARD/84478 Screening for CVD HCPCS code 84478
COLO/G0104 Colorectal screening HCPCS code G0104
COLO/G0105 Colorectal screening HCPCS code G0105
COLO/G0106 Colorectal screening HCPCS code G0106
COLO/G0120 Colorectal screening HCPCS code G0120
COLO/G0121 Colorectal screening HCPCS code G0121
FOBT/G0328 Fecal occult blood test HCPCS code G0328
FOBT/82270 Fecal occult blood test CPT code 82270
IPPE/G0344 Initial preventive physical examination HCPCS code G0344
IPPE/G0366 Initial preventive physical examination HCPCS code G0366
IPPE/G0367 Initial preventive physical examination HCPCS code G0367
IPPE/G0368 Initial preventive physical examination HCPCS code G0368
DIAB/82947 Diabetes screening HCPCS code 82947
DIAB/82950 Diabetes screening HCPCS code 82950
DIAB/82951 Diabetes screening HCPCS code 82951
PCBE/G0101 Pelvic and clinical breast examination HCPCS code G0101
PPV Pneumococcal pneumonia virus vaccination
PROS/G0102 Prostate screening HCPCS code G0102
PROS/G0103 Prostate screening HCPCS code G0103
GLAU Glaucoma screening
MAMM Screening Mammography
PAPT Screening Pap Test
HIBC/G0445 High intensity behavioral counseling to prevent sexually transmitted infections face to face HCPCS G0445
AAA/G0389 Screening for Abdominal aortic aneurysm HCPCS code G0389
PTWR/G9143 Pharmacogenomic testing HCPCS code G1943
IPPE/G0402 Initial preventive physical examination face to face visit HCPCS code G0402
IPPE/G0403 Electrocardiogram, routine ECG with 12 leads performed as a screening with Initial preventive physical examination HCPCS code G0403
IPPE/G0404 Electrocardiogram, routine ECG with 12 leads; tracing only performed as a screening with Initial preventive physical examination HCPCS code G0404
IPPE/G0405

Electrocardiogram, routine ECG with 12 leads; interpretation report only performed as a screening with Initial preventive physical examination HCPCS code G0405

PULM/G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour per session, up to two sessions per day HCPCS code G0424
CR Cardiac rehabilitation
ICR Intensive cardiac rehabilitation
AWV/G0438 Annual wellness visit; includes a PPPS, initial visit HCPCS code G0438
AWV/G0439 Annual wellness visit; includes a PPPS, subsequent visit HCPCS code G0439
BEHV/G0447 Face to face behavioral counseling for obesity, 15 minutes HCPCS code G0447

Use the <F6> key to scroll forward on the Preventive Services page. Additional services and next eligible dates are shown:

Preventive Services screen 2 of 2 provides additional dates of eligibility for preventive screenings, including HCPCS/CPT code

Field Description
TELH/99231 Subsequent hospital care, per day, for the evaluation and management of a patient HCPCS code 99231
TELH/99232 Subsequent hospital care, per day, for the evaluation and management of a patient HCPCS code 99232
TELH/99233 Subsequent hospital care, per day, for the evaluation and management of a patient CPT code 99233
TELH/99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99307
TELH/99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99308
TELH/99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99309
TELH/99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient CPT code 99310
BEHV/G0442 Annual alcohol misuse screening, 15 minutes HCPCS code G0442
BEHV/G0443 Brief face to face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443
BEHV/G0444 Annual depression screening, 15 minutes HCPCS code G0444
BEHV/G0446 Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face to face annual, 15 minutes HCPCS code G0446
BONE/77078 Bone density testing, Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) CPT code 77078
BONE/77080 Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg., hips, pelvis, spine) CPT code 77080
BONE/77081 Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites;appendicular skeleton (peripheral) (eg, radius, wrist, heel) CPT code 77081
BONE/76977 Bone density testing, Ultrasound bone density measurement and interpretation, peripheral site(s), a method CPT code 76977
BONE/G0130 Bone density testing, Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) HCPCS code G0130
BEHV/G0473 Behavioral counseling for obesity HCPCS code G0473
HCAS/G0472 Hepatitis C antibody, screening, for individual at high risk and other covered indication(s) code G0472
BONE/77085 Bone density testing, Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment CPT code 77085
COCS Cervical cancer screening
LDCT/G0297 Low Dose CT scan for lung cancer screening code G0297
HPVS/G0476 Screening for HPV HCPCS code G0476
HIVS HIV Screening
BONE/0508T Ultrasound measurement of bone density in shin bone

Use the <F8> key to continue to the next page of the CWF.

CWF Entitlement Screen provides dates of entitlement and termination, benefit period data, therapy cap information

Field Description
CLAIM Medicare number
NAME Beneficiary’s first initial and last name
D.O.B. Date of birth
SEX Sex code:
U = Unknown
M = Male
F = Female
APP DT Not used
REASON CD Reason code:
1 = Status inquiry
2 = Inquiry relating to an admission
DATE/TIME Date and time stamp YYDDDHHMMSS
REQ ID Not used
DISP CD Disposition code:
01 = Part A inquiry approved; beneficiary has never used Part A services
02 = Part A inquiry approved; beneficiary has some prior Part A utilization
03 = Part A inquiry rejected
04 = Qualified approval—may require further investigation
05 = Qualified approval—this inquiry begins new benefit period
TYPE Type of reply:
3 = Accept
CENT D.O.B. Century indicator for date of birth:
8 = 18th century
9 = 19th century
D.O.D. Date of death if one has been received from CWF
A: CURR-ENT DT Current Part A entitlement date
A: TERM DT Current Part A termination date
A: PRI-ENT DT Prior Part A entitlement date
A: TERM DT Prior Part A termination date
B: CURR-ENT DT Current Part B entitlement date
B: TERM DT Current Part B termination date
B: PRI-ENT DT Prior Part B entitlement date
B: TERM DT Prior Part B termination date
LIFE: RSRV Lifetime reserve days remaining
LIFE: PSYCH Lifetime PSYCH days remaining

Benefit Period Data (Current and Prior)

Field Description
FRST BILL DT Date of earliest billing action
LST BILL DT Date of latest billing action
HSP FULL DAYS Full inpatient hospital days remaining in current benefit period
HSPPART DAYS Inpatient hospital coinsurance days remaining in the current benefit period
SNF FULL DAYS Full inpatient SNF days remaining in current benefit period
SNF PART DAYS Inpatient SNF coinsurance days remaining in the current benefit period
INP DED REMAIN Inpatient deductible remaining to be met in the current benefit period
BLD DED PNTS Inpatient Part A blood deductible pints remaining to be met in the current benefit period
CURR B: YR Indicates the year to which the information pertains
CASH Part B cash deductible remaining to be met
BLOOD Part B blood deductible remaining to be met
PSYCH PSYCH Part B limit remaining to be met
PT Part B physical therapy limit remaining to be met
OT Part B occupational therapy limit remaining to be met
PRIR B: YR Indicates the prior Part B benefit year
CASH Cash deductible remaining to be met for prior Part B benefit year
BLOOD Blood deductible remaining to be met for prior Part B benefit year
PSYCH Psychiatric limit remaining for prior Part B benefit year
PT Physical therapy limit applied YTD for prior Part B benefit year
OT Occupational therapy limit applied YTD for prior Part B benefit year

Use the <F8> key to continue to the next page of the CWF.

CWF HMO Enrollment Screen provides plan data for HMO plan, dates of enrollment/termination

Field Description
DATA IND Indicators

Position 1 – Part B buy-in
0 = Does not apply
1 = State buy-in involved

Position 2 – Alien indicator
0 = Does not apply
1 = Alien nonpayment, provision may apply

Position 3 – Psychiatric pre-entitlement
0 = Does not apply
1 = Psychiatric pre-entitlement reduction applied

Position 4 – Reason for entitlement
0 = Normal entitlement
1 = Disability (DIB)
2 = ESRD
3 = Has or had ESRD, but current DIB
4 = Working age, but has or had ESRD
8 = Has or had ESRD and is covered under premium Part A
9 = Covered under premium Part A

Position 5 – Part A buy-in
0 = No Part A buy-in
1 = Part A buy-in applies

Position 6 – Rep Payee indicator
0 = Does not apply
1 = Selected for general enrollment period (GEP) contact
2 = Has rep payee
3 = Both conditions apply
NAME Full name of beneficiary in last name, first name, middle initial format
ZIP Beneficiary ZIP code
PLAN ENR CD Indicates the number of periods of enrollment:
0 = 0
1 = 1
2 = 2
3 = more than 2
CURR PLAN: Current plan
CURR: ID Five-position current plan identification number:
1 = H (constant)
2 and 3 = state code
4 and 5 = Plan number
OPT Option code– Describes whether the plan is restricted or unrestricted.

Unrestricted
1 = MAC processes all Part A and B provider bills
2 = HMO plan processes bills for directly provided services and for services from providers with effective arrangements

Restricted
A = MAC processes all Part A and B bills
B = HMO plan processes bills only for directly provided services
C = HMO plan to process all bills
ENR Enrollment Date– Effective date of current entitlement
TERM Termination date of current enrollment
PRIR PLAN: Prior plan
PRI ID Identifies prior plan– Five-position field:
Position 1 = H or 1–9
Position 2 and 3 = state code
Position 4 and 5 = plan number within the state
OPT Identifies whether the prior plan services are restricted or unrestricted.

Unrestricted
1 = MAC processes all Part A and B claims
2 = HMO processes all directly provided services

Restricted
A = MAC processes all Part A & B claims
B = HMO processes all directly provided services
C = HMO processes all claims
ENR Enrollment date of prior plan
TERM Identifies prior plan termination date
OTHER ENTITLEMENTS OCCURRENCE CD/DATE Identifies first two occurrence codes and dates indicating another federal program or insurance as primary payer.

Occurrence code – One-position field
1 = Workers’ Compensation
2 = Black lung
A = Working-aged beneficiary or spouse
B = ESRD beneficiary in coordination period and covered by EGHP
C = Medicare conditional payment pending final resolution
D = Automobile no-fault or other liability insurance
E = Workers’ Compensation and/or black lung
F = Veteran’s administration, public health, or other federal agency program
G = Working disabled beneficiary or spouse
H = Black lung
I = Veteran’s Administration

Date– Six-position field according to occurrence code
1 or 2 = Effective date of program
A–I = Date of previous claim where Medicare is secondary
ESRD CD/DATE End-stage renal disease code and date– Displays method selection information for dialysis patients:
1 = Method 1
2 = Method 2
Date = Month and year of selection (MMYY format)
This field displays two occurrences of data
CAT DATA: PSYCH The number of psychiatric days remaining (based on a maximum benefit of 190 days)
CAT DATA: DISCHG Discharge date from inpatient stay in a psychiatric hospital
CAT DATA: IND Identifies discharge date:
0 = initialized
1 = interim
CAT DATA: DAYS USED Psychiatric days used
CAT DATA: BLOOD Identifies number of blood pints carried over from 1988 to 1989
YR Reports the year to which the data applies
APP Identifies whether a December inpatient stay was applied to the current year deductible
MET Identifies amount of inpatient deductible to be met
BLD Blood deductible pints remaining to be met
CO SNF coinsurance days available
FL SNF full days available
FRM Date of earliest billing action for this benefit period
TO Date of latest billing action for this benefit period
IND Yearly data indicators—three positions.

Position 1
0 = Not used
2 = Clerical involvement
3 = Christian Science/SNF usage
4 = Both 1 and 2

Position 2
0 = Not used
1 = Through date is interim

Positions 3 and 4
For future use
INT Intermediary number
ADM Date of admission
FRM Statement covers from date
TO Statement covers to date
APP Inpatient deductible applied
ADJ IND Type of adjustment:
0 = No adjustment
1 = Downward adjustment
2 = Upward adjustment
CALC DED Calculated deductible—amount of inpatient deductible calculated
CMS DT Date that transaction was processed by CMS

Use the <F8> key to continue to the next page of the CWF.

CWF HMO Enrollment Screen provides plan data for HMO plan, dates of enrollment/termination

Field Description
HH-REC Home health record
CN Medicare number
NM Last name
IT First initial
DB Date of birth
SX Sex (M – male; F – female)
TECHCOM Identifies the date of mammography screening interpreted by a technician
PROCOM Identifies the date of mammography screening requiring interpretation by a physician
MAMMO RSK Indicator that describes beneficiary risk:
Y = High-risk
N = Not at high-risk
MAMMO DATES Date of last screening mammogram (up too three may be listed)

Transplant Information

Field Description
COV IND Indicates covered or noncovered transplant:
C = Covered
N = Noncovered
TRAN IND Indicates type of transplant done:
1 = Allogeneic bone marrow
2 = Autologous bone marrow
H = Heart
K = Kidney
L = Liver
DIS DATE Date of discharge from hospital inpatient stay in which transplant procedure was done
EPISODE START Identifies the start date of an episode
EPISODE END Identifies the end date of an episode
DOEBA Identifies the first service date of the HH PPS period
DOLBA Identifies the last service date of the HH PPS period

Use the <F8> key to continue to the next page of the CWF. Please note: beneficiary hospice information is available for up to four hospice election periods.

CWF Hospice screen provides hospice enrollment information including start date, provider details, number of days billed

Field Description
PERIOD Hospice period – Identifies the specific hospice election period. Four different periods may be displayed, depending upon the number of election periods that the beneficiary may have already used. Valid values are 1, 2, 3, or 4.
1ST ST DATE First start date – Displays the first start date of the beneficiary’s effective period with the first hospice provider that the beneficiary chose during the period
PROV Provider number – Identifies the number of the Medicare hospice provider
INTER Intermediary number – Identifies the intermediary number of the hospice provider
OWNER CHANGE ST DATE Change of ownership start date – Displays the start date of a change of ownership for the first provider, within the period
2ND ST DATE Second start date – Displays the start date of the beneficiary’s effective period with the second hospice provider that the beneficiary chose to use during the period
TERM DATE Termination date – Displays the termination date of the beneficiary’s election period
1ST BILLED DT First date of service billed under the hospice election
LAST BILLED DT Last date of service billed under the hospice election
DAYS BILLED The cumulative number of days billed to date for the beneficiary under the hospice election
REVO IND Indicates whether hospice coverage revocation occurred:
0 = No revocation
1 = Revocation of benefits for this election period

Use the <F8> key to continue to the next page of the CWF. Please note: the SMOKING AND TOBACCO USE CESSATION COUNSELING SERVICES screen will display only if CWF has data on the auxiliary file to be returned for the beneficiary’s Medicare number.

Field Description
MID Medicare ID number
LN Last name up to six letters
FI First initial
DOB Date of birth MM/DD/YYYY
SEX Sex code (M – male; F – female)
COUNSELING PERIOD Refers to five years of data that will be displayed—will display numerics of 1–5 years
TOTAL SESSIONS Number of sessions billed
HCPCS HCPCS code – Either G0375 or G0376
FROM Displayed as MM/DD/CCYY
THRU Displayed as MM/DD/CCYY
PER Period refers to five years of data that will be displayed and will contain a 1–5
QT Quantity– Refers to number of services billed for each date
TP Claim type
O = Outpatient
B = Part B

Use the <F8> key to continue to the next page of the CWF. Please note: there may be up to five pages of MSP data available.

CWF MSP Screen provides other insurer information, including policy numbers, employer data, effective and termination dates

Field Description
EFFECTIVE DATE Effective date of coverage
SUBSCRIBER NAME Name of subscriber
TERMINATION DATE Termination date of coverage
POLICY NUMBER Subscriber policy number
MSP CODE Code that identifies the Medicare Secondary Payer (MSP) program
A = Working aged (value code 12)
B = ESRD beneficiary in coordination period (value code 13)
C = Conditional Medicare payment
D = Auto no-fault or any liability insurance (value code 14)
E = Workers’ Compensation (WC) (value code 15)
F = Public Health Services (PHS) or other federal agency (value code 16)
G = Disabled (value code 43)
H = Black lung (value code 41)
I = Veteran’s Administration (value code 42)
L = Liability (value code 47)
W = WC Set-aside
Z = Medicare Part A
INSURER TYPE Type of primary insurer
A = Insurance
B = group health plan (GHP) HMO
D = Third Party Administrator (TPA) arrangement under an Application Services Organization (ASO) contract
E = TPA arrangement with stop loss insurance
F = Self insured/self administered
G = Collectively bargained health and welfare fund
H = Multiple employer health plan with at least one employer who has more than 100 full and/or part-time employees
I = Multiple employer health plan with at least one employer who has more than 20 full and/or part-time employees
J = Hospital services only plan
K= Medical services only plan
M = Medicare supplement
PATIENT RELATIONSHIP Subscriber relationship to patient:
01 = Spouse
18 = Self
19 = Child
20 = Employee
21 = Unknown
39 = Organ donor
40 = Cadaver donor
53 = Life partner
G8 = Other relationship
REMARKS CODES Contractor information to assist in additional development—two-position field (values are determined by the contractor)

Insurer Information

Field Description
NAME Name of insurer
GROUP NO Group number
ADDRESS Address of insurer
NAME Name of insurance group

Employer Data

Field Description
NAME Name of employer
EMPLOYEE ID Identification number assigned by the employer
ADDRESS Employer’s address
EMPLOYEE INFO To whom the employment data applies:
P = Patient
S = Spouse
M = Mother
F = Father
ADDRESS Employer’s address

[Return to FISS/DDE Provider Online Guide Index]

FISS/DDE Provider Online Guide: Chapter IV - Beneficiary/CWF (10)
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