Submitting Secondary Claims with COB Data Elements - Facilities

Transcription

1 Overview Submitting Secondary Claims with COB Data Elements - Facilities This supplement to the billing section of the AmeriHealth Caritas Pennsylvania Claims Filing Instruction Manual provides specific coding information on the submission of electronic provider-to- payer* coordination of benefits (COB) claims. The required COB data elements for submitting Electronic Data Interchange (EDI) claims to AmeriHealth Caritas PA may be gathered from the previous payer s adjudication, in both paper and Electronic Remittance Advice (ERA 835) formats. Specifications To submit provider-to-payer coordination of benefits (COB) claims via EDI, you must have a system, data entry process, or clearinghouse able to: Create or forward claims directly to EDI in: - The HIPAA 837 format; or - A format containing equivalent information. - AND - Process payment information by: -Receiving a HIPAA-standard Electronic Remittance Advice (ERA) format from the previous payer; or - Coding a paper remittance into the electronic claim. EDI Terminology Please refer to the following definitions for EDI terminology used throughout Hoosier s online application. Data Element Provides the names used in the ASC X12N 837 implementation guides, including X223A2. Loop/ Provides the exact location of each data element in the 837 format. Requirements Hoosier s COB data requirements align with HIPAA guidelines. The 837 Implementation Guide may also be found online at Questions? If you have questions regarding this communication, please contact the EDI Technical Support Hotline at or at edi@amerihealthcaritaspa.com *Please note payer-to-payer COB claim submissions are not supported by EDI. July

2 837I COB DATA FIELDS 837 I Other Information if other payers are known to potentially be involved in paying this claim Other Information may repeat 10 times 2320 Individual Relationship 2320 Reference Identification Sized To SBR 3 SBR01 P S T Primary Secondary Tertiary SBR 2 SBR02 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship Ref 837I SBR 12 SBR03 Group/ Policy Responsibility of Previous Payer Patient s Relation-ship to Insured s Group 2320 Claim Filing Indicator SBR 2 SBR09 Refer to the X223 Health Care Claim Institutional (837) document for acceptable values Ref 837I Identifying Type of Claim 2

3 2320 Claim Group 837 I Claim Level if claim has been adjudicated by payer identified in this loop and has claim level adjustment information. Sized To CAS 2 CAS01 CO CR OA Contractual Obligation Correction or Reversal Other May be present one time per Group PI Payer Initiated Reductions 2320 Claim Reasons 2320 Monetary CAS 5 CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 CAS 10 CAS03 CAS06 CAS09 CAS12 CAS15 CAS Quantity CAS 10 CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 PR Refer to the X223 Health Care Claim Institutional (837)/005010X221 Health Care Claim Payment/Advice (835) document for acceptable values Patient Responsibility Claim Reason s Units of Service being adjusted As received on the 835 from previous payer As received on the 835 from previous payer 3

4 837 I Payer Prior Payment when the present payer has paid an amount to the provider towards this bill COB-Payer paid amount 2320 AMT- Remaining Patient Liability 2320 COB Total Non- Covered AMT02 Size AMT 10 AMT01 D Monetary AMT 10 AMT01 EAF Monetary AMT 10 AMT01 A8 Monetary Prior Payment all AMT02s contain a Monetary No Covered charges- Actual 4

5 837 I Other Insurance Coverage to specify information associated with other health insurance coverage OI Other health Information 2320 OI Other health Information AMT02 Size OI 1 OI03 N No W Not Applicable Y - Yes OI 1 OI06 I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Benefits Assignment Certification Benefits Assignment Certification 5

6 837 I Other when loop 2320 is used (If SBR submitted, this loop is required). Other AMT02 Size NM1 2 NM101 IL Insured or Sub-scriber Entity Type Qualifier NM1 1 NM Person Non-Person Insured or Last or Org NM1 20 NM103 Insured Last First NM1 10 NM104 Insured First Middle NM1 1 NM105 Insured Middle Suffix NM1 NM107 Situational Identification Qualifier NM1 NM108 MI Member ID Member ID II Standard Unique Health Identifier ID NM1 20 NM109 s ID number at the previous Payer 6

7 837 I Other Address when provider has the other subscriber address on file. N4 is required when N3 is present. Other Address 1 N3 30 N301 Address line 1 Other Address 2 N3 12 N302 Address line 2 Other City N4 20 N401 City Other State N4 2 N402 State Abbreviation Postal N4 9 N403 Postal /Zip Country N4 N404 When the Address is outside of the United States of America 7

8 837 I Other Secondary Information when additional ID s are required. Secondary ID Qualifier Secondary ID Sized To REF 2 REF01 SY Social Security REF 20 REF02 Other Insured Additional Identifier when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. 8

9 837 I to send all known information on other payers in this loop. of NM1 2 NM101 PR Payer / Carrier Entity Qualifier NM1 2 NM102 2 Non-Person Entity Organization NM1 16 NM103 Payer Payer ID Qualifier Payer ID NM1 NM108 PI Payer ID XV Health Care Financing Admin National Plan ID NM1 15 NM109 ID Emdeon Payer ID 9

10 837 I Address by MDWise Hoosier Alliance, although this segment is required to be sent only when provider needs to identify the address for paper claims. N4 is required when N3 is present. Address Line 1 Sized To N3 18 N301 Address Line 1 Address Line 2 N3 18 N302 Address Line 2 City N4 15 N401 City State N4 2 N402 State Abbreviation Postal Country N4 9 N403 Postal /Zip N4 N404 when the Address is outside of the United States of America 10

11 837 I Claim Adjudication Date when loop ID 2430 Line Adjudication Date is not used and this payer has adjudicated the claim. Adjudication Date Sized To DTP DTP Date Claim Paid Date Qualifier DTP DTP02 D8 Date in CCYYMMDD Date Time Period DTP 8 DTP03 Adjudication or Payment Date 837 I Secondary Information This segment is required when a secondary number is needed to identify the payer. Payer ID REF 2 REF01 2U Sized To Payer ID EI Employer Identification FY NF Claim Office National Association of Ins. Comm. Reference ID REF 15 REF02 Secondary ID 11

12 837 I Patient Information if claim has been previously adjudicated by payer identified in loop. Either line or claim level is expected, if both are submitted, line level must add up to claim level. Sized To 2430 ID SVD 15 SVD01 ID Payer ID from 2430 Monetary 2430 Composite Medical Procedure 2430 Product/ Service ID 2430 Product/ Service ID SVD 10 SVD02 Service Line Paid SVD SVD03-1 See 837 IG SVD 7 SVD03-2 Procedure 2430 Procedure 2430 Procedure 2430 Procedure 2430 Procedure SVD 2 SVD03-3 Procedure SVD 2 SVD03-4 Procedure SVD 2 SVD03-5 Procedure SVD 2 SVD03-6 Procedure 2430 Description SVD SVD03-7 Procedure information 2430 Quantity SVD 10 SVD05 Quantity 2430 Assigned SVD 6 SVD06 Bundled or un-bundled Line if other payer bundled/unbundled this service line 12

13 837 I Line s when the prior payment had service line adjustments reported on a remittance. Either line or claim level is expected, if both are submitted, line level must add up to claim level Claim Adj Group 2430 Claim Adj Reason 2430 Monetary Sized To CAS 2 CAS01 CO CR OA PI PR CAS 5 CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 CAS 10 CAS03 CAS06 CAS09 CAS12 CAS15 CAS Quantity CAS 10 CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 See 837/ 835 IG Cont. Obl Corr/Rev Other Adj Payer Red Pat Resp Claim Reason s Units of Service being adjusted 13