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Claim Page 03 – Entering a Notice of Election (NOE) or Transfer NOE

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

Screen Shot

Key:

  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, dependent on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field
Field Name/Requirement UB-04 Form Locator (FL) Description

CD
Required

N/A

FISS defaults to a "Z". Do not change. NOEs should be submitted with Medicare as the primary payer.

PAYER
Required

FL 50

FISS will automatically plug "Medicare" into this field.

RI
Required

FL 52

Release of Information.

Valid values are:

I

Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes,

Y

Yes, provider has a signed statement permitting release of information.

MEDICAL RECORD NBR
Optional

FL 3b

Beneficiary's medical record number.

DIAG CODES
Required

FL67A-Q

For claims with a "From" date prior to October 1, 2015, enter the ICD-9-CM diagnosis codes. For claims with a "From" date on or after October 1, 2015, enter the ICD-10-CM diagnosis code(s). (Maximum of 25 codes.)

Note: Hospices may not report V-codes as the primary diagnosis on hospice claims. In addition, effective with dates of service on or after October 1, 2014, certain diagnosis codes as the principal diagnosis are prohibited, including debility, adult failure to thrive, as well as certain dementia codes. See Attachment AExternal PDF in Change Request 8877 for a list of all codes.

ATT PHYS NPI
Required

FL 76

Enter the National Provider Identifier (NPI) of the patient's attending physician. The attending physician is identified by the patient at the time they elect the hospice benefit. If the patient does not have an attending physician, enter the NPI of the certifying physician.

L
Required

FL 76

Enter the last name of the attending physician. If the patient does not have an attending physician, enter the last name of the certifying physician.

F
Required

FL 76

Enter the first name of the attending physician. If the patient does not have an attending physician, enter the first name of the certifying physician.

M
Optional

N/A

Enter the middle initial of the attending physician.

REF PHY NPI
Conditionally Required

FL 78 and 79

Enter the NPI of the physician responsible for certifying the patient as terminally ill, if different than the attending physician.

L
Conditionally Required

FL 78 and 79

Enter the last name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

F
Conditionally Required

FL 78 and 79

Enter the first name of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

M
Optional

N/A

Enter the middle initial of physician responsible for certifying the patient as terminally ill, if different than the attending physician.

Additional FISS Claim Pages

Updated: 04.07.21

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