Coordination of Benefits (COB) Professional

Transcription

1 Coordination of Benefits (COB) Professional Submitting COB claims electronically saves providers time and eliminates the need for paper claims with copies of the other payer s explanation of benefits (EOB) attached. In order to submit COB claims electronically, providers will need to understand Anthem s COB filing requirements along with the data contained within their practice management system, vendor software and the claim format. Benefits of filing COB claims electronically: Reduces paper and administrative expenses Takes advantage of automated remittance posting capabilities Provides consistent method of claims submission Increases quality due to reduction in manual intervention Introduces all advantages of electronic submission o Reporting and audit trail o Faster claims payment o Notification within 24 hours of acceptance or rejection Working with the Software Vendor: Does the software have COB submission capability? Is an upgrade required? What are the costs? Has the EDI vendor passed COB testing with Anthem in Virginia and are they submitting COB claims? If currently submitting COB claims electronically to Medicare, what is needed to submit COB to Anthem in Virginia? Will the software systematically post the COB information from the 835 payment advice? How is COB information posted in the software and submitted electronically from a paper EOB? Anthem COB Filing Requirements: The information necessary to send COB claims electronically to Anthem in Virginia should be obtained from the provider s practice management system, Explanation of Medicare Benefits (EOMB), payer EOB or 835 payment advice. To assist providers and their practice management and/or software vendor(s) in identifying COB filing requirements, Anthem has prepared the chart on the following pages that includes: Four easy steps when working with the practice management and/or software vendor List of CMS-1500 electronic claim requirements Instructions for submission of Medicare and commercial secondary claims Anthem COB front-end edit requirements CMS-1500/HIPAA conversion matrix

2 Follow These Steps for Electronic Submission of COB Claims Step 1 Determine the COB information to be sent electronically by reviewing the Anthem filing requirements outlined below. To view COB instructions online, visit the Anthem Companion Guide or EDI Publications link at the Anthem in Virginia s EDI Web site Data Required for Anthem COB Claims: Is Anthem primary, secondary or tertiary Name of the other insurance s subscriber (member) Name of the other insurance carrier Other insurance member identification number Other insurance type, such as commercial, auto, group, Medicare, etc. Other insurance deductible Other insurance approved amount Other insurance paid amount Other insurance coinsurance amount Other insurance non-covered amount Step 2 Work with the practice management and/or software vendor to determine if the data listed above is available within either of the system(s). Add the necessary data fields as appropriate and determine method of retrieving the information from the EOMB, payer EOB or the electronic 835 payment advice for electronic submission. When posting payments from the 835 payment advice, claim software vendors can often provide an automated solution to obtain the other insurance and payment information transferring this information directly to the electronic claim submission software. When posting payments from paper remittances, providers often need to work with their practice management and software vendor together to identify any additional fields and/or information needed to submit COB claims electronically. Step 3 Work with the vendor(s) to ensure all required fields are added and can be passed from the practice management and/or software vendor s system to Anthem for processing. Ask the EDI vendor to review the HIPAA Implementation guide submission requirements and Anthem s front-end COB edits to ensure COB claims submitted are error-free. Step 4 Request that the EDI vendor send a test file to the Anthem Open Network when your systems are ready to submit COB claims electronically. Anthem in Virginia is always available to test with EDI vendors. This ensures that the claims submitted are HIPAA-compliant and meet Anthem s requirements. Call our EDI specialist toll free at (800) to schedule a test. Select option 2 and then option 2 again.

3 CMS-1500/HIPAA Conversion Matrix Coordination of Benefits Chart The information in this chart refers to COB data only. For complete instructions on the 837P, refer to the 837P Implementation Guide and the Anthem Companion Guide available at Select Virginia and the Companion Guide link is on the left. You will also need the values from the UB92 Billing Specifications. Our EDI Specialists are available to speak with you, your vendor or clearinghouse Monday through Friday, 8 a.m. to 5 p.m., EST. Dial (804) (Richmond-area callers) or toll free (800) (outside Richmond). Select option 2 and then option 2 again. Report Claim Level Detail COB Information Is Anthem Primary, Secondary, Tertiary? 2000B, SBR01 P = Primary S = Secondary T= Tertiary Required for compliance Enter the appropriate value to identify Anthem s COB responsibility for this claim. Name of Other Insurance Carrier 11c 2330B, NM103 Enter name of other insurance Required when 2000B, SBR01 Name of Other Insurance Subscriber Other Insurance Identification Number 2330A, NM103, 104 Enter insured s first and last name A, NM109 Enter the other insurance member identification number Required when 2000B, SBR01 Required when 2000B, SBR01 Other Insurance Subscriber Information 2320, SBR01 P = Primary S = Secondary T= Tertiary Required for compliance Enter appropriate value to identify Anthem s COB responsibility for this claim.

4 COB Information Medicare & Commercial Name of Other Insurance Group 11b 2320, SBR04 Enter the name of the other insurance group Required when available (Note: Enter UNKNOWN when not available) Claim Adjustments (Requires three data elements in the 837P) 2320, CAS01 OA (Other Adjustment) Report the Group Code value listed to signify additional information is being reported. Medicare Only (Note: When deductible amount(s) are identified on the 835 payment advice, EOMB or payer EOB at the line level it is necessary to report the combined total at the claim level.) Other Insurance Allowed Amount (Requires two data elements in the 837P) Line Adjudication Information (Service Line Paid Amount) 2320, CAS02 1 (Deductible) Report the Adjustment Reason Code value listed to signify deductible being reported 2320, CAS03 Amount 2400, AMT01 AAE (Approved amount) 2400, AMT02 Amount 2430,SVD02 Amount Enter the corresponding monetary amount. Calculate and enter the combined total deductible amount for each of the service lines. Enter the approved amount for each service line from the Medicare EOMB, payer EOB or 835 payment advice. Enter a paid amount for each service line reported on the Medicare EOMB, payer EOB or 835 payment advice. Required, if other insurance paid amount is entered Required, if other insurance allowed amount is entered

5 COB Information CAS Line Adjustment (Requires three data elements in the 837P) Note: Report Deductible, Coinsurance, co-payment, non-covered services using the CAS segments as described 2430,CAS01 Various from the 837P Implementation Guide 2430, CAS02 Various from the 837P Implementation Guide 2430, CAS03 Amount Enter the appropriate Adjustment Group Code as found on the 835 payment advice or as identified on the EOB, Remittance or EOMB. Deductible, co-insurance, copayment and / or non-covered services can be reported using this segment. Enter the appropriate Adjustment Reason Code as found on the 835 payment advice or as identified on the EOB, Remittance or EOMB. Deductible, co-insurance, copayment and / or non-covered services can be reported using this segment. Enter the corresponding monetary amount. (Note: When reporting information from other than 835, mapping to HIPAA values may be required. See IG for valid values) (Note: When reporting information from other than 835, mapping to HIPAA values may be required. See IG for valid values) Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc. and Priority Health Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association.