Decoding CMS FI Inpatient/SNF Claim Records: A Comprehensive Guide

Understanding the complexities of CMS FI Inpatient/SNF (Skilled Nursing Facility) claim records can be challenging. This guide provides a detailed breakdown of the FI_IP_SNF_CLM_REC record, its structure, and key data elements. We'll explore the purpose of each field, its limitations, and how it contributes to the overall claims processing within the Centers for Medicare & Medicaid Services (CMS).

Demystifying the FI Inpatient/SNF Claim Record (NCH)

• Purpose: This record, officially known as "FI_IP_SNF_CLM_REC," is a standardized format for inpatient and SNF claim data.
• Aliases: You might also see it referred to as "UTLIPSNL."
• Data Source: The information originates from the CA Repository on DB2T.

Navigating the Claim Record's Structure

The FI Inpatient/SNF Claim Record is organized into groups to streamline data management and processing. Understanding these groups helps in locating specific information.

1. FI Inpatient/SNF Claim Fixed Group

This group serves as the foundation for the entire record. It's a comprehensive section, spanning from position 1 to 2058 of the record.

2. Claim Record Identification Group

• Location: Positions 1-8.
• Function: Establishes core identification elements for internal NCH processing.
• Key Fields: Includes record length, version code, record identification code, and NCH derived claim type code, especially crucial as of Version 'I'.

3. Record Length Count

• Positions: 1-3
• Data Type: Packed (PACK)
• Description: The length of the complete claim record, measured in bytes. Essential for accurate data interpretation.
• Historical Note: Populated retroactively to 1991 during Version H conversion.
• Aliases: REC_LNGTH_CNT (DB2 & Standard), REC_LEN (SAS)

4. NCH Near-Line Record Version Code

• Positions: 4-4
• Data Type: Character (CHAR)
• Description: Indicates the record version within the Nearline file. This helps track changes in data structure over time.
• Aliases: NCH_REC_VRSN_CD (DB2), REC_LVL (SAS), NCH_NEAR_LINE_REC_VRSN_CD (Standard), and NCH_VERSION (Title alias).
• Length: 1 character
• Code Table: NCH_NEAR_LINE_REC_VRSN_TB

5. NCH Near Line Record Identification Code

• Positions: 5-5
• Data Type: Character (CHAR)
• Description: Identifies the type of claim record being processed.
• Aliases: NEAR_LINE_RIC_CD (DB2), RIC_CD (SAS), NCH_NEAR_LINE_RIC_CD (Standard), and RIC (Common & Title alias).
• Length: 1 character
• Code Table: NCH_NEAR_LINE_RIC_TB

6. NCH MQA RIC Code

• Positions: 6-6
• Type: CHAR (Character)
• Function: Identifies records processed through CMS' CWFMQA system. Important for internal editing.
• Note: Populated starting 10/3/97; earlier claims contain spaces.

7. NCH Claim Type Code

• Positions: 7-8
• Type: CHAR (Character)
• Function: Identifies the claim record type (e.g., HHA, SNF, Outpatient). Essential for proper routing and processing.
• Note: Expanded over versions H, I, and J to include more claim types, including Medicare Advantage claims.

The NCH Claim Type Code leverages several fields for comprehensive derivation:

• NCH CLM_NEAR_LINE_RIC_CD
• NCH PMT_EDIT_RIC_CD
• NCH CLM_TRANS_CD
• NCH PRVDR_NUM
• CLM_MCO_PD_SW
• CLM_RLT_COND_CD
• MCO_CNTRCT_NUM
• MCO_OPTN_CD
• MCO_PRD_EFCTV_DT
• MCO_PRD_TRMNTN_DT

Here are the rules for how the Claim Type Code is set:

• CLM_TYPE_CD = 10 (HHA CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V','W' OR 'U'
  • PMT_EDIT_RIC_CD EQUAL 'F'
  • CLM_TRANS_CD EQUAL '5'
• CLM_TYPE_CD = 20 (SNF NON-SWING BED CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V'
  • PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
  • CLM_TRANS_CD EQUAL '0' OR '4'
  • POSITION 3 OF PRVDR_NUM IS NOT 'U', 'W', 'Y' OR 'Z'
• CLM_TYPE_CD = 30 (SNF SWING BED CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V'
  • PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
  • CLM_TRANS_CD EQUAL '0' OR '4'
  • POSITION 3 OF PRVDR_NUM EQUAL 'U', 'W', 'Y' OR 'Z'
• CLM_TYPE_CD = 40 (OUTPATIENT CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'W'
  • PMT_EDIT_RIC_CD EQUAL 'D'
  • CLM_TRANS_CD EQUAL '6'
• CLM_TYPE_CD = 50 (HOSPICE CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V'
  • PMT_EDIT_RIC_CD EQUAL 'I'
  • CLM_TRANS_CD EQUAL 'H'
• CLM_TYPE_CD = 60 (INPATIENT CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V'
  • PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
  • CLM_TRANS_CD EQUAL '1' '2' OR '3'
• CLM_TYPE_CD = 61 (INPATIENT 'FULL' ENCOUNTER CLAIM - PRIOR TO HDC PROCESSING - AFTER 6/30/97 - 12/4/00):
  • CLM_MCO_PD_SW = '1'
  • CLM_RLT_COND_CD = '04'
  • MCO_CNTRCT_NUM, MCO_OPTN_CD = 'C'
  • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
• CLM_TYPE_CD = 61 (INPATIENT 'FULL' ENCOUNTER CLAIM -- EFFECTIVE WITH HDC PROCESSING):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'V'
  • PMT_EDIT_RIC_CD EQUAL 'C' OR 'E'
  • CLM_TRANS_CD EQUAL '1' '2' OR '3'
  • FI_NUM = 80881
• CLM_TYPE_CD = 62 (Medicare Advantage IME/GME CLAIMS - 10/1/05 - FORWARD):
  • CLM_MCO_PD_SW = '0'
  • CLM_RLT_COND_CD = '04' & '69'
  • MCO_CNTRCT_NUM, MCO_OPTN_CD = 'C'
  • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
• CLM_TYPE_CD = 63 (HMO NO-PAY CLAIMS):
  • CLAIMS PROCESSED ON OR AFTER 10/6/08
    • CLM_THRU_DT ON OR AFTER 10/1/06
    • CLM_MCO_PD_SW = '1'
    • CLM_RLT_COND_CD = '04'
    • MCO_CNTRCT_NUM, MCO_OPTN_CD = 'A', 'B' OR 'C'
    • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
    • ZERO REIMBURSEMENT (CLM_PMT_AMT)
  • CLAIMS PROCESSED PRIOR to 10/6/08
    • MCO_CNTRCT_NUM, MCO_OPTN_CD = 'A', 'B' OR 'C'
    • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
    • ZERO REIMBURSEMENT (CLM_PMT_AMT)
• CLM_TYPE_CD = 64 (HMO CLAIMS PAID AS FFS):
  • CLAIMS PROCESSED PRIOR to 10/6/08
    • MCO_CNTRCT_NUM, MCO_OPTN_CD = '1', '2' OR '4'
    • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
  • CLAIMS PROCESSED on or after 10/6/08
    • CLM_RLT_COND_CD = '04'
    • MCO_CNTRCT_NUM, MCO_OPTN_CD = '1', '2' OR '4'
    • CLM_FROM_DT & CLM_THRU_DT ARE WITHIN THE MCO_PRD_EFCTV_DT & MCO_PRD_TRMNTN_DT ENROLLMENT PERIODS
• CLM_TYPE_CD = 71 (RIC O non-DMEPOS CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'O'
  • HCPCS_CD not on DMEPOS table
• CLM_TYPE_CD = 72 (RIC O DMEPOS CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'O'
  • HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table).
• CLM_TYPE_CD = 81 (RIC M non-DMEPOS DMERC CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'M'
  • HCPCS_CD not on DMEPOS table
• CLM_TYPE_CD = 82 (RIC M DMEPOS DMERC CLAIM):
  • CLM_NEAR_LINE_RIC_CD EQUAL 'M'
  • HCPCS_CD on DMEPOS table (NOTE: if one or more line item(s) match the HCPCS on the DMEPOS table).

8. Fiscal Intermediary Claim Link Group

• Positions: 9-133
• Length: 125
• Description: Introduced with Version 'I', this group maintains claim segment integrity (up to 10 segments). Also used for sorting and final action processing.
• Standard Alias: FI_CLM_LINK_GRP

9. Claim Locator Number Group

The Claim Locator Number Group is an 11-character field found in positions 9-19 and is critical for identifying the beneficiary.

• Common Alias: HIC
• Standard Alias: CLM_LCTR_NUM_GRP
• Title Alias: HICAN

10. Beneficiary Claim Account Number

• Positions: 9-17
• Type: Character (CHAR)
• Function: Identifies the primary beneficiary under SSA or RRB programs.
• Common Alias: CAN

11. NCH Category Equatable Beneficiary Identification Code

• Positions: 18-19
• Type: CHAR (Character)
• Function: Categorizes groups of BICs, facilitating matching of records with different BICs for the same beneficiary.

12. Beneficiary Identification Code

• Positions: 20-21
• Type: CHAR (Character)
• Function: Identifies the relationship between the individual and a primary SSA or RRB beneficiary.

13. NCH State Segment Code

• Positions: 22-22
• Type: CHAR (Character)
• Function: Identifies the segment of the NCH Nearline file containing the beneficiary's record for a specific service year. Effective 12/96, segmentation is by CLM_LCTR_NUM, then final action sequence within residence state. (Prior to 12/96, segmentation was by ranges of county codes within the residence state.)

14. Beneficiary Residence SSA Standard State Code

• Positions: 23-24
• Type: CHAR (Character)
• Function: Captures the SSA standard state code of the beneficiary's residence. Used for payment rate determination and billing language preference.

15. Claim From Date

• Positions: 25-32
• Type: NUM (Numeric)
• Format: YYYYMMDD
• Function: The first day on the billing statement covering services rendered to the beneficiary.
• Note: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match.

16. Claim Through Date

• Positions: 33-40
• Type: NUM (Numeric)
• Format: YYYYMMDD
• Function: The last day on the billing statement covering services rendered to the beneficiary.
• Note: For Home Health PPS claims, the 'from' date and the 'thru' date on the RAP (initial claim) must always match.

17. NCH Weekly Claim Processing Date

• Positions: 41-48
• Type: NUM (Numeric)
• Format: YYYYMMDD
• Function: Indicates the Friday on which the weekly NCH database load process cycle begins. Claims are loaded to the Nearline file during this cycle.

18. CWF Claim Accretion Date

• Positions: 49-56
• Type: NUM (Numeric)
• Format: YYYYMMDD
• Function: The date the claim record is posted to the beneficiary master record at the CWF host site and authorization for payment is returned.

19. CWF Claim Accretion Number

• Positions: 57-58
• Type: PACK (Packed)
• Length: 3 Signed
• Function: Sequence number assigned to the claim record on the accretion date. Indicates the claim's processing position within that day.

20. FI Document Claim Control Number

• Positions: 59-81
• Type: CHAR (Character)
• Length: 23
• Function: A unique identifier assigned by the intermediary to an institutional claim.
• Common Alias: ICN (Intermediary Control Number)

21. FI Original Claim Control Number

Continue to consult your documentation for field 21 onward, and this guide will have helped you better understand the basics!