Flag 6 – Payment Adjustment

Value Description 

0       No payment adjustment 

1       Paid standard amount for pass-through drug or biological (status indicator G)

2       Payment based on charge adjusted to cost (status indicator H) 

3       Additional payment for new drug or new biological applies to APC (status indicator ‘J’)*

 4      Deductible not applicable (specific list of HCPCS codes) 

5       Blood/blood product used in blood deductible calculation 

6       Blood processing/storage not subject to blood deductible

7       Item provided without cost to provider 

8       Item provided with partial credit to provider 

91-99 Each composite APC present, same value for prime and non-prime codes. 

Flag 7 – Payment Method 

Value Description

 0        OPPS Pricer determines payment for service 

 1        Based on OPPS coverage, or billing rules, the service is not paid

 2       Service is not subject to OPPS 

 3       Service is not subject to OPPS, and has an OCE line item denial or rejection

 4        Line item is denied or rejected by you; OCE not applied to line item

Flag 8 – Line Item Action

Transferred from input, for Pricer, and can impact selection of discounting formula

Value Description 

0        OCE line item denial or rejection is not ignored 

1        OCE line item denial or rejection is ignored 

2        External line item denial. Line item is denied even if no OCE edits 

3        External line item rejection. Line item is rejected even if no OCE edits 

4        External line item adjustment. Technical charge rules apply  

Flag 9 – Composite Adjustment 

Value Description

 01     No composite group assigned 

01     First composite group on claim

02     Second composite group on claim 

03-    ZZ Nth composite group on claim