Submitting Secondary Claims with COB Data Elements - Practitioners

Transcription

1 Submitting Secondary Claims with COB Data Elements - Practitioners Overview This supplement to 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 Pennsylvania may be gathered from the previous payer s adjudication, in both paper and electronic (835) Remittance Advice 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 (835 ERA) format from the previous payer - Coding a paper remittance into the electronic claim. EDI Terminology Please refer to the following definitions for EDI terminology used throughout AmeriHealth Caritas Pennsylvania s online application. Data Element Provides the names used in the ASC X12N 837 implementation guides, including X096A1 and X098A1. Loop/ Provides the exact location of each data element in the 837 format. Requirements AmeriHealth Caritas Pennsylvania 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.

2 837P COB DATA FIELDS 837 P Other Information if other payers are known to potentially be involved in paying this claim. Loop ID Sized To Value Value Notes 2320 Other Information may repeat 10 times SBR 1 SBR01 P S T Primary Secondary Tertiary 2320 Individual Relationship 2320 Reference Identification 2320 Insurance Type 2320 Claim Filing Indicator 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 837P SBR 12 SBR03 Group/ Policy SBR 2 SBR05 See 837 IG Insurance Type Responsibility of Previous Payer Patient s Relationship to Insured s Group SBR 3 SBR09 Ref 837P Identifying Type of Claim

3 837 P Claim Level if claim has been adjudicated by payer identified in this loop and has claim level Loop ID 2320 Claim Group 2320 Claim Reasons 2320 Monetary adjustment information. Sized Value Value Notes To CAS 2 CAS01 CO Contractual Obligation CR Correction or Reversal OA Other PI Payer Initiated Reductions PR Patient Responsibility 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 Refer to the X222 Health Care Claim Professional (837)/005010X221 Health Care Claim Payment/Advice (835) document for acceptable values Claim Reason s Units of Service being adjusted May be present one time per Group As received on the 835 from previous payer As received on the 835 from previous payer

4 837 P Payer Prior Payment when the present payer has paid an amount to the provider towards this bill. Loop ID 2320 Payor Paid 2320 Noncovered charged amount 2320 Owed AMT02 Sized To Value Value Notes AMT 10 AMT01 D Monetary Payer Paid AMT 10 AMT01 A8 Monetary Non-covered charged amount AMT 10 AMT01 EAF Monetary 837 I Other Insurance Coverage Owed to specify information associated with other health insurance coverage. Loop ID 2320 OI Other health Information 2320 OI Other health Information AMT02 Size OI 1 OI03 N No W Not Applicable Y - Yes Element Value Notes 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 Loop ID 837 P Other when loop 2320 is used (If SBR submitted, this loop is required). Other Entity Type Last or Org Sized To Value Value Notes NM1 2 NM101 IL Insured or NM1 1 NM Person Non- Person NM1 20 NM103 Insured Last Insured or First NM1 10 NM104 Insured First Middle NM1 1 NM105 Insured Middle Prefix NM1 NM106 Not Used Suffix NM1 NM107 Suffix Identification NM1 NM108 MI Member ID Member ID Standard II Unique Health Identifier ID NM1 20 NM109 s ID number at the previous Payer

6 837 P Other Address when provider has the other subscriber address on file. N4 is required when N3 is Loop ID Other Address 1 Other Address 2 Other City Other State Postal Country present. Sized To Value Value Notes N3 30 N301 Address line 1 N3 12 N302 Address line 2 N4 20 N401 City N4 2 N402 State Abbreviation N4 9 N403 Postal /Zip N4 N404 When the Address is outside of the United States of America

7 Loop ID 837 P Other Secondary Information when additional ID numbers are required. Secondary ID Sized To Value Value Notes REF 2 REF01 SY Social Security when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity.

8 Loop ID 837 P Other Payer to send all known information on other payers in this loop. of other payer Entity Organization Payer ID Payer ID Sized To Value Value Notes NM1 2 NM101 PR Payer NM1 2 NM102 2 Non- Person Entity NM1 16 NM103 Payer NM1 NM108 PI Payer ID Health XV Care Financing Admin National Plan ID NM1 15 NM109 ID Emdeon Payer ID

9 837 P Other Payer Address N4 is required when N3 is present. Loop ID Other Payer Address Line 1 Sized To Element Value Notes N3 18 N301 Address Line 1 Other Payer Address Line 2 N3 18 N302 Address Line 2 Other Payer City N4 15 N401 Other Payer City Other Payer State N4 2 N402 Other Payer State Abbreviation Other Payer Postal Other Payer Country N4 9 N403 Other Payer Postal /Zip N4 N404 when the Address is outside of the United States of America

10 837 P Claim Check or Remittance Date when loop ID 2430 Line Adjudication Date is not used and this payer has adjudicated the Loop ID Adjudication Date Date Date Time Period claim. Sized To Value Value Notes DTP DTP Date Claim Paid DTP DTP02 D8 Date in CCYYM- MDD DTP 8 DTP03 Adjudication or Payment Date 837 P Other Payer Secondary ID and Reference This segment is required when a secondary number is needed to identify the payer. Loop ID Value Value Notes Payer ID REF 2 REF01 2U Payer ID EI FY NF Employer Identification Claim Office National Assoc of Ins. Comm. Reference ID REF 15 REF02 Other Payer Secondary ID

11 837P Line Adjudication Information This segment is required when a secondary number is needed to identify the payer. Loop ID Value Value Notes 2430 ID SVD SVD01 ID Payer ID from 2430 Monetary 2430 Composite Medical Procedure 2430 Product/ Service ID 2430 Product/ Service ID 2430 Procedure 2430 Procedure 2430 Procedure 2430 Procedure SVD SVD02 Service Line Paid SVD SVD03-1 See 837 IG SVD SVD03-2 Procedure SVD SVD03-3 Procedure SVD SVD03-4 Procedure SVD SVD03-5 Procedure SVD SVD03-6 Procedure 2430 Description SVD SVD03-7 Procedure information 2430 Revenue SVD SVD04 Revenue 2430 Quantity SVD SVD05 Quantity 2430 Assigned SVD SVD06 Bundled or unbundled Line Not Used if other payer bundled/ unbundled this service line

12 837P Line s when the payer identified in Loop made line level adjustments which caused the Loop ID 2430 Claim Adj Group 2430 Claim Adj Reason 2430 Monetary amount paid to differ from the amount originally charged Value Value Notes CAS CAS01 CO Cont. Obl CR Corr/Rev OA Other Adj PI Payer Red PR Pat Resp 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 Claim Reason s Units of Service being adjusted

13 837P Line date or Remittance Date when the service line adjudication has been performed. Loop ID Value Value Notes 2430 Date Claim DTP DTP Paid 2430 Date DTP DTP02 D Payment Date DTP DTP03 Service Adjudication or Payment Date