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Claim Page 01 – Correcting a Notice of Election (NOE)

For notices of election (NOEs) with the "From" dates on or after January 1, 2018, hospice providers may submit an NOE to correct an election date. The following information explains how to enter the NOE to correct an election date using the Fiscal Intermediary Standard System (FISS) Claims/Attachments option (FISS Main Menu option 02) via Direct Data Entry (DDE). The corresponding UB-04 Form Locator (FL) is also identified. NOEs may also be submitted via Electronic Data Interchange (EDI). Refer to CMS 837I NOE Companion Guide for the required elements.

Claim Page 01 (Map 1711) contains general patient information, condition codes, occurrence codes, occurrence span codes and value codes.

Begin entering data on Claim Page 01 and continue until the necessary fields are completed. Use the key and table below to determine what fields are required and what information to enter.

Note: The codes listed on this page represent those most frequently submitted on hospice claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

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 Descriptions for Claim Page 01 – Map 1711
Field Name/Requirement	UB-04 Form Locator (FL)	Description
MID Required	FL 60	Enter the beneficiary's Medicare ID number
TOB Required	FL 4	Type of bill (system generated). FISS Page 01 defaults the type of bill (TOB) to 81A. You may need to change this depending on the TOB you are entering. 81A – Freestanding hospice 82A – Hospital based hospice
NPI Required	FL 56	Enter your National Provider Identifier.
PAT.CNTL# Optional	FL 3a	Up to 20 digits are available for you to enter your internal account number for tracking purposes. This number will display on your Remittance Advice or your Electronic Remittance Advice
STMT DATES FROM Required	FL 6	Enter the correct effective date of this hospice election in MMDDYY format. The date must match the ADMIT DATE and the date reported with Occurrence Code 27.
LAST Required	FL 8	Enter the beneficiary's last name exactly as it appears on the beneficiary's eligibility file, including any spaces, apostrophes, hyphens or suffixes.
FIRST Required	FL 8	Enter the beneficiary's first name exactly as it appears on the beneficiary's eligibility file.
MI Optional	FL 8	Enter the beneficiary's middle initial.
DOB Required	FL 10	Enter the beneficiary's date of birth.
ADDR 1-6 Required	FL 9	Enter the beneficiary's full mailing address, including street name and number, post office box number or RFD, city and state.
ZIP Required	FL 9	Enter the beneficiary's 5- or 9- digit zip code.
SEX Required	FL 11	Enter the beneficiary's gender using the appropriate alpha character. M = Male F= Female
MS Optional	N/A	Beneficiary's marital status
ADMIT DATE Required	FL 12	Enter the correct effective date of the hospice election.
COND CODES Required	FL 18-28	Effective for NOEs with the "From" date on or after January 1, 2018. Enter D0 (zero). Note: When D0 is entered, Occurrence Code 56 and date must also be submitted.
OCC CDS/DATE Required	FL 31-34	Occurrence code 27 – Enter the correct date of certification. This date must match what is entered in the FROM date and ADMIT DATE. Occurrence code 56 – Enter the incorrect date of certification (the date submitted on the original NOE). Effective for NOEs with the "From" date on or after January 1, 2018.
FAC.ZIP Required	FL 1	Facility zip code of the provider or the subpart (9-digit).

Refer to the Claim Page 03 – Entering a Notice of Election (NOE) or Transfer NOE for the remaining data elements that need to be submitted when correcting an NOE.
Additional FISS Claim Pages

Notice of Elections (NOEs)/Transfer NOE
- Claim Page 01
- Claim Page 03
Hospice Claims
Notice of Election Termination/Revocation (NOTR) – 8XB
- Claim Page 01
- Claim Page 03

Updated: 04.14.21

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Claim Page 01 – Correcting a Notice of Election (NOE)

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