Group Minutes X12N TG2 WG2 Health Care Claims February 7-10, 2005

Transcription

1 Group Minutes X12N TG2 WG2 Health Care Claims February 7-10, 2005 Chair(s) Name Company Term End Date Phone John Bock Individual Member After February 2006 meeting Ph: Tom Drinkard Individual Member After June 2006 meeting Ph: et Conny Nichols Claredi After February 2007 meeting Ph: om Doug Renshaw Highmark After October 2005 meeting Ph rk.com Secretary(s) Name Company Term End Date Phone Katie Sullivan Fox Systems Ph: Ph: Ph: Quorum Requirement Statement (please check one) This group enforces quorum requirements for group voting items. This group does not enforce quorum requirements for group voting items. X Work Products and Status (e.g. Transaction Sets, Implementation Guides, UN/CEFACT development, etc.) Work Product ID Work Product Name Work Product Status # (if applicable) X222 Health Care Claim: Professional Draft X223 Health Care Claim: Institutional Draft X224 Health Care Claim: Dental Draft X225 Health Care Service: Data Reporting Draft- Next Trimester Meeting Notification Date: June 2005 Location: San Diego, CA Contact Person: John Bock, Tom Drinkard, Conny Nichols, Doug Renshaw Agenda (include key items): DMs DSMOs Other Business Elections Scheduled (include position and term dates): Special Meeting Notification (e.g. Interim Conference Calls, Industry Meetings, Regulatory Agency Meetings, etc.) Date: Conference Calls 2 nd and 4 th Thursdays of the month 1:00 PM EST. Next call to be held February 24, :00pm EST. Location: Conference Call (full workgroup) Contact Person: John Bock Agenda: Other Business

2 Date: Interim Meeting April 25-27, 2005 Location: St. Louis, Missouri Contact Person: John Bock, Doug Renshaw Agenda: 5010 Comments Review Executive Summary of Current Meeting (optional, but recommended): Date: Location: Agenda: Summary of Major Accomplishments: Elections Held (include position, term dates, and individual s name): Date and Minutes of Current Meeting Date: February 7-10, 2005 Location: Nashville, TN DM At a previous meeting the workgroup approved a DM to change C023 Health Care Service Location Information composite data element. The change was done to accommodate the increase in bill type from 3 to 4 characters and changed the min/max of C from 1/2 to 2/3 (Note: C does not contain the last part of the bill type which is claim frequency code carried in C023-03). DM also needs to ensure there is a correct semantic note and modify the definition. Change 1331 to Code identifying where services were or may be performed: the National Uniform Billing Committee facility type code for institutional services or the place of service codes for professional or dental services. Note: Removed language regarding this being the first and second position of the bill type. Motion: To move forward the modified DM for approval. Discussion: Question: How does this impact place of service codes? This does not affect the place of service codes, it only changes it in terms of how many bytes it could be the code source does not change. Today in the UB manual the type of facility is constructed from 2 one character codes the 1 st character plus the 2 nd character but will now be a single code and that single code is still part of the composite that is combined with the claim frequency code to form the complete type of bill. (Parts 1 and 2 of the 3 parts used to create a bill type will now be a single part and may be 3 bytes, so there will only be 2 parts for creating a bill type) Decision: Motion carries with 3 abstentions Drafts The 5010 implementation guides are out for public comment (comment period is open through March 26 th 2:00 PM EST). Workgroup anticipates a large number of comments and workgroup must respond to each of these comments. In order to have the informational forum as scheduled in June, workgroup must have posted all responses 15 days prior to the informational forum.

3 Anything during this trimester meeting that comes up and results in a change will need to have a comment submitted to the webboard in order to officially address. Note: Positive comments are equally important as any negative ones. Public Review Guides can be downloaded through the WPC either by accessing through shopping feature or from the initial Welcome comment as posted to each on-line conference on the webboard: Interim Meeting An interim meeting has been scheduled in order to address all comments and to meet the deadline for having the informational forum at the June trimester meeting. Where: St. Louis Airport Hilton When: April 25 th -April 27 th - (To begin 8:00am Monday and adjourn 3:30pm Wednesday). Reservations: or 800-HILTONS, or Group Rate: $79 per night (single or double) Group Name: Claims Work Group ; Meeting Code = CLA It is expected that participants will arrive on Sunday, April 24 th, 2005 and depart after 3:30pm Wednesday. Currently 29 workgroup members have confirmed they will participate with an additional 12 who will likely participate. Once a member knows they can attend they should notify John or Doug in order for them to address the room block size. Note: The interim meeting is to address comments only as posted to the webboard. List Serve Issue List Serve Issue- The workgroup currently has 2 list serves, one that is using a non-standard list serve address. The workgroup is attempting to get both of these list serves merged into one and if possible have this change be seamless to its users, however there is a possibility that you might get a confirmation . Note the following two address: X12n837@listman.disa.org (old address that will go away) X12ntg2wg2@listman.disa.org (address that will stay) Co-Chair Nominations Open Nominations are open for Conny s Co-Chair Position. Conny Nichols will be re-running.

4 HIR Process There was a Web-portal established where people in the industry can request of X12 a HIPAA Interpretation. There are 3 primary contacts, 1 for each of the guides: -Teresa Jensen- Dental -Mark Carter- Professional and -Laurie Burckhardt - Institutional If you would like to follow the discussion surrounding HIRs and the responses, send John Bock your WPC login ID and you will be added to the list. There is a 7-day discussion surrounding the HIR response with an additional discussion once final proposed response is posted. If there are no issues brought forward in the final 2 days the WG2 response is final. To date there have been about 15 HIRs: 3-4 Professional guide Institutional guide 0 Dental guide Several responses have been sent back from TG2 based on other discussions. Question: Have any of these responses gone back to the submitter yet? Response: Yes. Question: Are there webboards used for the workgroup HIRs? Response: Yes, but not all workgroups are using the webboard nor is it clear as to where workgroups are posting/having discussions surrounding their HIRs. Webboard Address: webboard.wpc-edi.com/~tg2-wg2 It was suggested that TG2 feedback surrounding responses be constructive and come with a recommended solution. Predetermination of Benefits CAQH initiative- has a 10 year goal to do what banking industry did and take back the transactions from government and put back to the private sector (coalition of payers and providers). Initially they will be addressing eligibility and trying to get industry agreement surrounding the implementation and use of the transactions. A formal comment and a request has come as a result of the CAQH initiative to have a predetermination of benefits functionality in the professional and institutional as is currently done in the dental Note: This is not typically a real time functionality in the dental, but the request is for this to be done in real time. In the dental transaction these requests are treated exactly like a claim and there is a catch all adjustment that takes all the money away and typically no dates of service. In the dental guide CLM19 has an indicator that shows it is a predetermination of benefits. Question: Is there payer buy-in for this request? Response: Can t answer that one way or another however it whether there is payer buy-in or not should not factor in our decision as this version of the transaction is years away. There were concerns that some of what is being requested should really be done or is already done in the 270/271 transactions, but there is a distinct difference between

5 what the eligibility transaction does vs. what a predetermination would do. Eligibility tells coverage and benefits they don t tell you what will be paid and an predetermination would be an estimate of payment at a particular point in time. Additional concerns were raised that in the medical claims processing world there are too many caveats and editing rules and felt any predetermination of benefits might create false expectations. However, it was noted that predetermination of benefits is not a guarantee of payment. In the dental world it is used as a tool used in development of a treatment plan. On the dental side there appears to be more treatment choices and may not be as beneficial on the medical side. Question: Would adding this functionality put a requirement on payers to support it? Response: No, this is not HIPAA mandated and whether there would be a push towards this was not discussed. Question: How is this handled in a payment history perspective? Response: This would likely just be another claim type in system that is specific to predetermination. The question the workgroup needs to answer is do we want to support predetermination of benefits outside of those done in dental? It was brought forward that per the charter if there is a business need, the workgroup should support, but this is only related to supporting in the standard not necessarily in the IGs. Concerns that the 271 does address benefit level information such as chiropractic services, but if the workgroup goes down this path where is the line between what is carried in the 271 vs. what is a predetermination. Note: This has been done for years in dental, the 271 addresses does this patient have coverage to these type of benefits and a predetermination answers the question if services were performed and billed today what would be paid. Motion: To table discussion until further business justification can be gathered Discussion: Some approved amounts need to be factored in to determine how much copays will be, for example if a copay is 20% the approved amount is necessary to determine what the patient may have to pay. Question: Does the pre-cert cover money amounts for the patient responsible amounts? Response: No, you can authorize a dollar amount but does not necessarily address patient responsibility. Decision: Motion carries with 1 opposed and 5 abstentions. Discussion tabled until additional information can be gathered, possibly on the next conference call. Minimum Necessary Changes Minimum necessary for Privacy doesn t typically apply to transactions, however X12 was informed by OHS and OCR that by virtue of the language X12 created form one of the situational rules it basically created optional elements. In the Dental and Professional guides there are approximately elements that fall into this category and for the Institutional and Reporting guides it is approximately The workgroup has several options for addressing this concern: Change notes to use the If not required by this implementation guide, do not send. Leave notes as is and add front matter surrounding submitter s responsibility in relation to minimum necessary. Question: What are the risks if we don t do anything? Response: If we don t look at changing the IG to address this concern there is a chance the 5010s may not be looked at for HIPAA guides. Question: What are the risks to the submitter s if we change the language? Response: There is a risk that changing language could result in tighter edits on the payer side and will result in more logic on the submitter s side as well. There were concerns that we don t want to take away the senders ability to send clarifying information and it was suggested that we should discuss with the provider forum for input. Note: Some of the elements are really not about sending clarifying information, but workgroup will need to look at data elements on a case-by-case basis. Question: What is timeline for addressing this? Response: this trimester meeting. Question: What changed

6 between the 4010A1 and now? Response: We didn t have the privacy rule with Question: Is this being addressed by other workgroups and what is management s position on which direction to move? Response: Yes, all workgroups will be reviewing this and X12 management guidance is to change situational rules to the form of if not required by this implementation guide, do not send. Question: Is there a documented memo regarding this? Response: Yes, this is an official memo that was send to TG4. Question: How would a companion guide affect your choice in the outcome, if the companion guide requires an element it must be sent? Response: Companion guides cannot require something the guide doesn t permit. Note: Part of the reason we wanted to put in, may be sent at submitter s discretion was to limit the rejections by payers should a transaction have extra data within the transaction. Question: How can workgroup make changes to the guides without being required to go out for public comment again and additional issues? Response: Whenever you go out to comment you it results in changes, workgroup is required to post these responses and changes. Any objections to changes made resulting from a comment can be raised at the informational forum. In order to mitigate the risk that the 5010 guide would not be adopted as a future HIPAA guide the workgroup split into a smaller group to review elements on a case-by-case basis. If not addressed below, the workgroup changed the situational rules for PHI elements to: If not required by this implementation guide, do not send. Institutional -Admitting diagnosis- Changed the situational rule to: Required when claim involves an inpatient admission. And if not required by this implementation guide do not send.. By removing the word hospital from the original situational rule this would point it back to the definition of inpatient as being defined by the NUBC and this would include an SNF. Question: In addition to defining what is inpatient will the NUBC also provide directions surrounding how to determine the bill type? Response: There really aren t any instructions surrounding the determination of type of bill, but noted the comment for the NUBC to take this under consideration. --DRG information- If it is a COB situation where there were multiple payers and each uses a different DRG version. Most payers will run claims through own grouper, is the DRG really necessary? Removed the DRG HI segment page 186. Professional --Billing provider level (2000A-PRV) segment taxonomy. Changed note to Required when a payer s adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Question: Are we going to change what is being done with the Institutional? Response: The bigger issue is in a COB situation with multiple payers where only 1 payer requires taxonomy, will need to address language that allows for all payers within a string to accept it if any one of the payers in the string needs it. With this change in wording the workgroup is saying if 3 payers are involved none of the payers could edit against its presence since they likely would not know the other payer s adjudication logic. --Line Note (2400- NTE) Change situational rule to Required when in the judgment of the provider the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Changed the note to use the word judgment because it is consistent with other language in the guide

7 --Rendering provider (2310B- PRV) Changed situational rule to Required when a payer s adjudication is known to be impacted by the Provider taxonomy code. If not required by this implementation guide, do not send. Note: Changes in the professional guide are mirrored in the dental guide and changes in the institutional guide are mirrored in the reporting guide when appropriate. --Duplicate Data at Claim and Service Level issue- Currently workgroup is developing language that would allow for information to be repeated at both the claim and service line levels. Misc Items -Universal Product Number- UPN (2400-REF) Question: Does anyone besides California use the Universal Product Number? California looking at collecting this information in the drug segment. -Procedure Code Composites- In the procedure code composites a description is required when using an NOC code. Discussion surrounding if it is necessary to supply a description when there is an NDC reported. It was determined that not all payers use the NDC codes in their payment processes and therefore a description would still need to be supplied. There was a need brought forward from the workgroup that would require a description for codes that did not fall into the NOC category such as those codes indicating generic drug. The situational rule needs to be modified to allow for its use under these circumstances. ACTION: Pam to work on situational language. -Drug Information Drug related info created for the professional transaction needs to be adapted for institutional. The intent is to submit this information through the comment period. -Feasibility of Combining Guides There was discussion surrounding the feasibility of combining the guides into one. This has been discussed at previous meetings and a sub-group was identified, but no additional discussion occurred. The team will regroup and research the pros and cons of combining the guides. DSMO #1016 Requests the addition of tooth number to the Professional claim. Oral surgeons are asking for the addition of tooth numbers to the professional claim to help solve their problem in receiving denials from medical payers. For example when a professional claim is submitted to a medical payer often the first extraction is paid and any additional extractions are denied as duplicates because when using the professional claim there is not way to differentiate between identical services for multiple teeth. The DSMO requests a modification to the 5010, but this is also an issue with the 4010A1l. Note: This is not just an oral surgical problem, but could impact others as well. It was suggested that the requester might want to pursue modifiers for identifying tooth numbers as this would be a fix for the 4010A1 as well as any future guides. Other suggestions included the use of the NTE segment, but this automatically puts the claim into a manual adjudication process. Question: Why wouldn t

8 these be billed on the dental claim? Response: Some of these claims require a diagnosis code for processing and the diagnosis code is not reportable in the dental claim for 4010A1. Note: This is also an issue for payer-to-payer COB, as some payers may require the use of dental claims while other will require the use of the professional claim. For the purposes of the 4010A1 the workgroup identified two possible solutions: -NTE Segment -Modifiers If the workgroup determined the NTE segment as the best option, it was recommended that a format be developed by the workgroup for the industry, but it is understood any format would simply be a recommendation. Question: Why would we consider the NTE segment when for other situations we would not use it? Response: The other situations such as the request for ambulance information, the workgroup was able to offer a different solution outside the use of the NTE segment e.g. service location. Question: If we move forward in the 5010 to allow tooth numbers in professional guide are we still going to require HCPCS codes rather than CDC? Response: HCPCS has license to Dental codes and can be reported as the D codes. Question: Is the driving force behind this issue COB concerns? Response: No, that is just one of several. Note: This DSMO item will be discussed and the upcoming NUCC and NUBC meeting. Motion: To table discussion until conference call Discussion: none Decision: Motion carries. Co-Chair Elections Motion: To close nominations. Discussion: None Decision: Motion carries with 0 opposed and 0 abstentions. Motion: To elect Conny Nichols by acclamation. Discussion: None Decision: Conny Nichols was re-elected to co-chair position. K3 Process There is a current situation where a state feels they have met the requirement for using the K3 segment, but the workgroup did not feel a case was brought forward in an official manner and approved to meet the usage note. The concern is that there should be a defined process as to when and how the K3 segment can be used and the process should detail what a state must do to request and receive approval for its use. The workgroup would do the analysis and X12N would ultimately decide there is no alternative. It was suggested to potentially use the new portal process. Concerns that the way the note is currently written is not as tight as it could be.

9 ACTION: Neil, Alan, Kelly will draft process language and work on situational rule for future guides. Below details the results of Alan, Neil, and Kelly s work. Propose to change K3 segment Situational Rule to: Required when approved for use in this implementation by the X12N committee based on an emergency legislative requirement. If not required by this implementation guide, do not send. Propose to change the K3 segment TR3 Notes: At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: - The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. - The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Institutional-Attending Provider Taxonomy- PRV In the institutional guide the billing provider has locations for reporting the NPI, a secondary ID utilizing the REF segment and the provider specialty information in a PRV segment. The PRV at the attending provider loop is no longer present. Concerns were expressed that the provider specialty information is still needed at the attending level since the billing provider is not always the attending provider. It went away because the billing provider cannot be a billing service and there did not appear to be a business reason for keeping it at the attending level, but now a business case was brought forward for keeping it. ACTION: Pam to work on situational rule and submit a comment for adding the PRV segment for attending provider. Institutional QTY --The institutional guide still has the QTY segment in loop This should have been removed. Workgroup should submit a comment to request the removal of this segment. ACTION: Todd to submit a comment regarding the removal of the QTY segment. CLM09 --For CLM09 the way the language is in the 5010 sounds like it doesn t allow a payer to require or a provider to require a signature at their discretion. It appears the only to options are to not collect a signature or have it because of state or federal law or to lie in the transaction. It was believed there is nothing in the privacy

10 regulation that prevents a payer from requiring a signature and there was concern the language in the makes it that a payer cannot require a signature. The language in the implementation guide does not preclude a provider from collecting a signature it does however preclude a payer from making a requirement that a signature must be collected. The notes for this particular element does not state if not required by this implementation guide, do not send as it is a required element. Therefore if a provider has collected a signature they may report it using the value Y. Question: Why can t the payer require a signature? Response: The intent was to take advantage of the privacy rule where it doesn t require a signature and as a standards setting body the intent was to not impose additional requirements that aren t needed. CLM07 --For CLM07 in the professional claim the situational rule states Required when the destination payer is Medicare.CLM07 indicates whether the provider accepts Medicare assignment for this claim. OR Required when the destination payer is not Medicare and a nonparticipating (non-par) provider is submitting a participating (par) claim. Sending the A code indicates that a non-par provider is advising the plan to adjudicate this specific claim under participating provider benefits as allowed under certain plans. If not required by this implementation guide, may be provided at the sender s discretion, but cannot be required by the receiver. The dilemma is the terminology of participating vs. non-participating is not used in all worlds, but rather the terms of network vs. non- network and a network provider does not necessarily have to accept assignment. The values associated with CLM07 are being misinterpreted and it was suggested to move notes surrounding the use code values from the situational rule to value notes. It was agreed to move code value information from situational rule to value notes. ACTION: Deb to submit comment to make this change. CN1- Contract Information There were concerns brought forward that some in the industry were looking at utilizing the CN1 segment as an option for getting around the NPI requirement. However, the situational rule specifically states this is for postadjudicated claims. Individual element notes do require some additional work. ACTION: Workgroup to submit comment to address element notes. Balancing It was suggested that the workgroup draft language to be included in the guide surrounding balancing of claims. A comment will need to be submitted with draft language. ACTION: John Bock and Bob Pozniak to draft language and submit comment. CLM11- Accident Indicator (Institutional) For the 5010 Institutional guide, the workgroup modified CLM11 accident indicator to coincide with what is in the Dental and Professional guides and the NUBC was going to remove the duplicative occurrence codes to ensure there was not multiple ways to report the same information. Upon further analysis it was determined that the occurrence codes provide a greater granularity than that available in CLM11 and should be maintained. Workgroup will need to change CLM11 to not used and add a REF segment for accident state. Workgroup will need to submit a comment to implement this change. ACTION: John and Todd to submit a joint comment.

11 Subscriber/Patient- Change of Structure Issues There were concerns brought forward surrounding the elimination of the patient loop when you have a unique member ID. This is not how this is being universally applied now. Concerns were expressed surrounding how payers would implement this and how a provider would know whether or not an ID was unique. This change needs to occur as this aligns the claim transactions with other X12 transactions such as the 270/271. The way the guide is today, requires both the subscriber and patient ID, but if a provider only has the patient ID, they cannot get the subscriber ID through the 270/271 since the current 270/271 does not return subscriber information if the number is unique to the client.. Discussion surrounding how provider determines if number is unique. This is a current operational problem, many provider s software have no way to know which number is carried in the system. Basically today, much of what information the provider uses is based on assumptions and changing the structure of the subscriber/patient loops doesn t fix this. The problem that exists today is outside the area in which X12 has any control, all X12 can do is ensure our transactions work together. Note: The decision to move in this direction was made with input from all parties. Billing Provider Secondary ID- REF There was discussion surrounding the position of billing provider secondary REF being at the highest level and applicable to everything rather than all the other identifiers being inside payer information at the individual claim. It was thought this was an oversight and we intended to move the billing provider secondary REF down to payer information. Will move REF segment to 2010BB loop. ACTION: The workgroup to submit a comment to make this change. Service Location In the service location loop the second piece of the situational rule references modifiers QB or QU modifiers indicating a Health Professional Shortage Area. This was added to meet Medicare needs, but is not longer necessary. It was recommended to second note. Question: How is the shortage bonus determined now? It is believed to be connected to the zip code. Just the second paragraph would be removed from the notes. WG will remove the second paragraph. ACTION: Comment needed to remove or statement in situational rule. 2310A Attending Provider- Institutional A comment was brought forward concerning the situational rule for use of the attending provider loop and concerns that there was some ambiguity surrounding it. The only place attending provider would not be required would be if you called 911 and requested an ambulance. Even if an ambulance is called from the emergency room it would be considered ordered and is thus scheduled. The suggestion to list services would likely result in missed services and therefore the workgroup determined to only list the single exception. An additional comment was brought forward concerning the terms used in the attending provider loop. It was noted that the loop was changed to indicated attending provider however the qualifier indicates physician. The qualifier is part of the standard and can t be modified, but the definitions added should clarify the meaning. It is possible to add a value note.

12 Note: The provider definitions are the same as they will be in the UB04 manual and there was a lot of provider input in the development of these definitions. Question: Will the attending physician ever be a resident? No, ultimately the supervisor would be the attending. SV206 Unit Rate- Institutional -Discussion surrounding whether or not this is a needed data element. It appears this can be calculated by dividing the line item charges by the units (SV203 divided by SV204 equals SV06). Other items that can be calculated have been removed from the guides, should this as well? Workgroup agreed this element does not appear to be necessary and will be changed to not used unless a business case is brought forward. Provider Secondary ID Qualifiers -There were concerns raised surrounding the removal of most the qualifiers for the provider secondary REF segments. Response: The additional qualifiers are no longer necessary since the secondary REFs are now located in the payer specific loops and you are not required to put in multiple numbers in a list where a payer would be required to select which number to use, rather payer specific loops carry the associated number. This is being done to eliminate the confusion that currently exists today and would occur regardless of NPI. There were additional concerns that this is being developed to support a change that will only be used for an interim period of time, However, there will still be a portion of the industry who will not get NPIs and this will be long term solution for those providers and will support sending both NPI and proprietary numbers during the NPI transition period. For payer-to-payer claims, it is the obligation of the first payer to move the appropriate payer information to the destination payer when forwarding claims. Institutional- Line Item Date and Statement Date -In the Institutional claim for line item date the situational rule among other things states it is used when the line item date is different than the statement covers period. There was some confusion surrounding what is exactly meant by the term different. The line item date is considered different than the statement date unless it is identical to the statement date for both start and end dates such as: Statement Date Line Item Date The following are examples of line item dates that are different than the statement date of : Line Item Dates: It seems reasonable that the workgroup should attempt to clarify this as there are a number of questions surrounding the issue. COB Instructions

13 A presentation was given providing an overview of COB tutorials developed for providers by New York Medicaid. The COB tutorials may be accessed at: by selecting the News and Resources Tab and scrolling down on the right hand side to find the COB link. The example uses remittance information available for either paper or the 835. The presentation emphasized the importance of balancing. For example the total charge amount (CLM) must equal the total of all the detail charge amounts (SV1 for professional). Additionally any previous payer adjudication information should also balance, all payments should equal the total amount paid in the AMT segment. It was stressed that this is how the world it is supposed to work, but not necessarily how things are currently being done. Draft 835 Issues At the adjustment reason code meeting there was discussion surrounding code value 23, which is used to identify the prior payer payment adjudication info in COB claims today. This has created some confusion and in attempt to clarify the group came up with 2 separate adjustment reason codes; 1 to indicate a prior payer s amount paid and 1 to indicate a reduction or adjustment amount of the primary payer that was used in consideration by the secondary payer. An example was presented as to how the draft 835 is structured, as it impacts what the workgroup does in the 837. For secondary claims the premise of how the 835 is built is to not report back what the primary did, but to report the impact the primary payment had on the payment of the secondary claim. Example presented: Claim 1 Payer 1 Charge =1000 Payer 1Allows= (1) CAS*CO *45*400 (contractual obligation of 400) CAS*PR*1*300 (patient responsibility of 300) Payer 1 paid 300 on claim. Claim 2 Payer 2 Charge= 1000 Payer 1 information set had a CO45 for 400 PR1 for 300 Payer 1 aid for 300 As the secondary adjudicates this, the information in the 835 indicates to adjudicate it at first as if you re primary. Payer 2 allows = 750 CO 45 for 250 (contractual obligation of 250) PR1 for 100 (patient responsibility of 100) Payment is 200 Payers have different ways of determining payment for secondary claims in this example the payer determines they will pay 200. The amount that is not accounted for is what was the result of the primary payers adjudication or the impact of the primary payers adjudication.

14 IMPACT of primary payer OA The idea for the draft 835 for secondary claims is to never reiterate what the primary did, all that has already been sent to the provider from the primary. A payer adjudicates like they are primary and take any additional adjustments because they are secondary and put them all into OA 23. Based on this structure, the secondary payer does not re-tell what the primary did and it wasn t felt a second adjustment reason code was needed. There were concerns that this structure doesn t resolve the problem, as credit balances are still being created and it is believed that this structure actually creates more credit balances because you are getting full contractual adjustments for both the primary and secondary payers. There are multiple approaches to doing this and any approach has its downfalls such as negative adjustments. It was suggested that any secondary claim information would have to be special handled. Some felt that this was not necessarily true since in a majority of the cases if you are sending a secondary claim and if the provider has a contractual relation with the primary payer, the provider is contractually obligated to deal with the primary payer s allowed amount. This means in the majority of cases a provider is asking the secondary payer to pay what is left as the patient responsibility. The 835 as drafted would require special handling for posting of claims secondary to Medicare which are a majority of the COB claims. Concerns were expressed that this structure appears to focus around the exception rather than the rule. The 835 and representatives from the 837 workgroup will meet to discuss potential optional solutions. Billing Provider Tax ID A comment will be submitted requesting that the tax ID not be part of the secondary REF for billing provider. For clarification purposes it will be suggested to break out the tax ID for billing provider into its own REF segment called Billing Provider Tax ID and allowing either the EI or SY qualifiers whichever qualifiers should be applicable for the transaction. Beginning in the 2010AA where NPI would be in NM108/NM109 and the next REF segment would be for the reporting of tax ID number with a TR3 note stating this is the tax ID number of the entity that s to be paid and it will have to be sent. There would be a second REF segment that would be used for the reporting of other identifiers with a repeat of 2 because this is to be used to report only those other identifiers that do not change across payers (state license number and UPIN number). Recommendation will include removal of G2 and LU qualifiers from this loop and placing them in the payer loop billing provider identification REF segment. The payer loop billing provider identification REF would have 2 repeats. The TR3 notes would be copied to this level to address its use pre and post NPI. The only qualifiers would be G2 and LU. In the other payer billing provider loop, first 2 notes would be left and notes 3 and 4 would be copied from the billing provider level. It is recommended to remove the qualifiers EI, SY, 0B, and 1G as these don t change from payer to payer. The example given was only for professional, but the presenter would submit similar comments for the dental and institutional guides as well. Other Payer Patient Loop The purpose of the other payer patient loop was to allow for the sending of a payer specific unique id for that payer and only came up when the patient was not the subscriber. In light the new philosophy surrounding the use of subscriber and patient loops, small workgroup met to determine if patient information is necessary in the 2330 and if payer-to-payer COB could occur without it. Example is color coded to show information moving through payers.

15 Coordination of benefits; the patient is not the subscriber; there are three payers. For both the primary and the tertiary payers, the patient has a unique identifier. For the secondary payer, the patient does not have a unique identifier. PATIENT: Ted Smith ADDRESS: 236 N. Main St., Miami, FL, GENDER: Male DOB: 05/01/1992 PATIENT RELATIONSHIP: Child SUBSCRIBER FOR PAYER A: Ted Smith (the patient) PAYER A ID NUMBER: PRIM SUBSCRIBER FOR PAYER B: Jane Smith (Ted s mother) DOB: 10/22/1963 PAYER B ID NUMBER: SEC SUBSCRIBER FOR PAYER C: Ted Smith (the patient) PAYER C ID NUMBER: TERT PATIENT: Ted Smith ADDRESS: 236 N. Main St., Miami, FL, SEX: M DOB: 05/01/1992 PATIENT RELATIONSHIP: Child DESTINATION PAYER A: PriJane Insurance Company ADDRESS: 123 First Street, South Miami, FL, PAYER A ID NUMBER: (TIN) DESTINATION PAYER B : Secondary Insurance Company ADDRESS: 456 Second Avenue., Chicago, IL ETIN#: DESTINATION PAYER C : Tertiary Insurance Company ADDRESS: 789 Third Street, Seattle, WA PAYER ID: BILLING PROVIDER: Dental Associates ADDRESS: 234 Seaway St., Miami, FL, NPI: TIN: RENDERING PROVIDER: Dr. Ben Kildare NPI: PATIENT ACCOUNT NUMBER: DOS=11/09/2004 POS=Office SERVICES RENDERED: Root Canal treatment for tooth #5 at $ ELECTRONIC ROUTE: VAN submits claim on behalf of billing provider to Payer A (receiver) (Example 2A) who adjudicates the claim. Payer A transmits back an 835 to the billing provider. The VAN then submits a second claim on behalf of the billing provider to Payer B (receiver) (Example 2B) VAN CLAIM IDENTIFICATION NUMBER FOR PAYER A: VAN CLAIM IDENTIFICATION NUMBER FOR PAYER B: VAN CLAIM IDENTIFICATION NUMBER FOR PAYER C: Payer A returned an electronic remittance advice (835) to the billing provider with the following amounts and claim adjustment reason codes: SUBMITTED CHARGES (CLP003): AMOUNT PAID (CLP04): PATIENT RESPONSIBILITY (CLP05): The CAS at the claim level was: CAS*PR*1*50**2*30~ (INDICATES A $50.00 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT AND THE BALANCE WAS PAID AT THE 80% COINSURANCE RATE). Payer B returned an electronic remittance advice (835) to the billing provider with the following amounts and claim adjustment reason codes: SUBMITTED CHARGES (CLP003): AMOUNT PAID (CLP04): PATIENT RESPONSIBILITY (CLP05): The CAS at the claim level was: CAS*OA*23*120~ (INDICATES $ PAID BY A PREVIOUS PAYER.) CAS*PR*1*50**2*15~ (INDICATES A $50.00 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT AND THE BALANCE WAS PAID AT THE 50%

16 COINSURANCE RATE). Payer A Payer B Payer C Subscriber: Ted Smith (child) ID: PrimChild01 Relationship: Self DOB: 05/01/1992 Payer: Subscriber Payer patient A stuff. (Primary) No Patient loop Subscriber: Jane Smith (mother) ID: SecMom02 DOB: 10/22/1963 Patient: Ted Smith (child) ID: (none) Relationship: Child DOB: 05/01/1992 Payer: Payer B (Secondary) Subscriber: Ted Smith (child) ID: TertChild03 Relationship: Self DOB: 05/01/1992 Payer: Payer C (Tertiary) No Patient Loop Other Subscriber: Jane Smith (mother) ID: SecMom02 Relationship: Child DOB: 10/22/1963 Other Payer: Payer B (Secondary) Other Subscriber: Ted Smith (child) ID: TertChild03 Relationship: Self DOB: 05/01/1992 Other Payer: Payer C (Tertiary) Other Subscriber: Ted Smith (child) ID: PrimChild01 Relationship: Self DOB: 05/01/1992 Other Payer: Payer A (Primary) Other Subscriber: Ted Smith (child) ID: TertChild03 Relationship: Self DOB: 05/01/1992 Other Payer: Payer C (Tertiary) Other Subscriber: Ted Smith (child) ID: PrimChild01 Relationship: Self DOB: 05/01/1992 Payer: Payer A (Primary) Other Subscriber: Jane Smith (mother) ID: SecMom02 Relationship: Child DOB: 10/22/1963 Other Payer: Payer B (Secondary) Institutional-HCPCS Modifiers A comment was brought forward surrounding what modifiers can be used in the SV2 segment for the institutional claim. The 4010 guide has a reference to the UB92 manual, however this is not the code source for the modifiers. The modifiers are part of the code sets as listed in SV202-1 (e.g. HCPCS). It was suggested to add some clarifying language surrounding modifiers and that they must correlate with the qualifier in SV Workgroup agreed to add an additional note that ties the sub-elements to the qualifier in SV Question: Does something similar need to be done in the professional? Response: Yes, but not in Dental. Meeting Announcements Workgroup Conference Calls- Will be held the 2 nd and 4 th Thursdays of each month from 1:00 PM-3 PM EST. Announcement: The next call is scheduled for Thursday, February 24, Announcement: TG2WG2 will have an interim meeting April 25 th April 27 th in St Louis.

17 N4 Segment TG2 has been working development of the changes to the N4 address segment. There was an issue surrounding the need to support 3 character codes for reporting some Mexico state codes. New element for reporting country subdivision code N407, N402 will continue to be used for the reporting of US and Canadian states or provinces. TG4 will submit comments to use the N407 Country subdivision code. 835/837 joint meeting Members for both the 835 and 837 workgroup met to determine how secondary claim payment information should be reported and how you represent the primary payers adjudication as part of the numbers. There were two approaches: From the code committee there was a move to have two codes: one to represent payment amount another to represent adjustment amount. After working through with 835 it came up with a recommendation to have only one code that represents (payment amount + contractual adjustment amount) of the primary that the secondary is taking into consideration in their pricing. Primary Payer Dr. 100 charge Payer allowed 110 Paid 90 CAS PR 20 CAS CO with 10 because payer allowed more than charge. Secondary Dr. 100 Charge Paid 20 patient responsibility CAS OA 23 of 80 dollars. Impact of prior payers adjudication is new type definition for code 23 The twist on this is when the secondary payers pricing does not necessarily base it on what the primary did. You will end up with a legitimate credit balance amount. Still working on development of language. Question: Can we expect to see documentation posted at some point? Response: The 835 workgroup will need to redo and post a comment. Repricer Model When a provider sends a claim to a repricer via a clearinghouse there was a concern that use of the payer loop for reporting of repricer information might not be appropriate. Suggested that either the payer loop name should change or additional verbiage be added to clarify this can be a repricer. Question: Is it appropriate to reporting repricer information in the payer loop? Response: Yes.

18 Question: How does the repricer know where to send the claim? Response: either use the group number assigned to the provider or they have an enrollment file based on recipient ID number. Does the workgroup want to explicitly address in notes or let the standard stand on its own. TR3 note will be deleted. ACTION: Workgroup comment needed. Claim Information duplicated at Service Level Review of situational notes removed the flexibility to send at submitter s discretion and would preclude a provider from duplicating information at the service level that was originally reported at the claim level. Will add statement when necessary for efficient transaction processing by the submitter to allow for information to be repeated at the service line level. There were concerns raised surrounding data storage and data management issues resulting from the potential for receipt of duplicate information in large volumes. Site ID Qualifier G5 for Provider site ID is missing from the Current practice is to use by clearinghouse as a parsing and routing mechanism for distributing reports. Question: Does anyone else have a concern (G5 qualifier in REF at the billing provider level)? Response: Workgroup members did not know if this was needed or not, but will do research and comment will be submitted surrounding the need for G5. A concern was raised surrounding the potential for people to attempt to circumvent the NPI, but this can be mitigated with tight usage notes and the NPI rule. Additionally it was discussed that this really isn t necessary for adjudication of the claim and that there are other ways to parse and route reports, but this is likely the most provider friendly method.