The following is an example of an 837P claim that has had two prior payers – prior to Medicaid. Our goal is to build a detailed, balanced 837 with both prior payer’s adjudication information. The claim is the same example we have used in other COB training documents. For clarity, again we will utilize generic paper remits to relay the prior adjudication to you - the reader.

First - Medicare:

Medicare pays $67 and leaves an $80 balance for AARP

Medicare leaves a balance of $80 (made up of $60 deductible and $20 coinsurance.) The claim is next filed with the secondary, Medicare Supplement. In our example we are using AARP as the supplemental “medigap” coverage. The 837P claim to AARP contained all the detail (2430 Level) adjudication information. We will say that AARP will cover the $20 coinsurance but will not pay the $60 deductible – in fact, in our hypothetical example AARP will apply the $60 to the deductible for the medigap plan. Ultimately, this will leave a $60 balance for Medicaid to consider.

Now – AARP:

AARP pays $20 and leaves a $60 balance for Medicaid

On the next page we will get our first look at how having two prior payers affects the 2000B, 2320, 2330A, and 2330B Loops / Segments.

Notice the SBR02 values at the 2000B SBR and the two iterations of the 2320 SBR.

• The current payer is Medicaid (2000B SBR02 = ‘T’ Tertiary)
• The primary payer is Medicare (1 st 2320 SBR02 = ‘P’ Primary)
• The secondary payer is AARP (2 nd 2320 SBR02 = ‘S’ Secondary)

Also notice the two 2320 AMT segments in each Loop 2320. If you are familiar with the claim, it becomes fairly clear what these values are. In the 1st 2320 Loop, Medicare paid $67 and left a balance of $80. The secondary payer has only to consider the value in the ”AMT*F2*80” as this represents the claim level patient responsibility according to the Primary Payer Medicare.

Notice the 2nd iteration of Loop 2320 – the two AMT segments tell us that the Secondary Payer AARP paid $20 (of the $80) and considers $60 to be patient responsibility.

The 3rd payer, Medicaid, will now consider the $60 balance.

But first, we will study how the claim was prepared by looking at the 2400 service lines and the two iterations (one for each prior payer) of the 2430 claim adjudication loops. The next page contains just the line item information from this claim. Following that display is a more in depth look at the detail in the 2430 adjudication loops complete with labels and balancing totals.





ISA*00* *00* *ZZ*TTTT *ZZ*MMISNYDOH *030707*1006*U*00401*000025781*0*P*:~
GS*HC*TTTT*MMISNYDOH*20030707*1615*25781*X*004010X098A1~
ST*837*219091~
BHT*0019*00*3920394930203*20031020*1615*CH~
REF*87*004010X098A1~
NM1*41*2*TEST MEDICAL CTR*****46*TTTT~
PER*IC*BETTY OFFICEMANAGER*EM*BOFFICEMGR@TESTMEDICAL.COM~
NM1*40*2*NYSDOH*****46*141797357~
HL*1**20*1~
NM1*85*1*TEST*ROBERT***M.D.*24*123456789~
N3*277 W 11TH ST~
N4*NEW YORK*NY*10003~
REF*1D*00123456~
REF*LU*003~
HL*2*1*22*0~
SBR*T*18**MEDICAID*****MC~ - - - - - - - - - - - - - - - - - - - Medicaid Tertiary
NM1*IL*1*MEMBER*IMA*T***MI*AA01148E~
N3*78 AVALON CT~
N4*DOYLESTOWN*PA*18901~
DMG*D8*19470920*F~
NM1*PR*2*NYSDOH*****PI*141797357~ __________________________________________________________________________________________

CLM*MEMBER CHART 0001*239***11::1*Y*A*Y*Y*B******P~
HI*BK:45781~
SBR*P*18*123456789A*MEDICARE PART B*MB****MB~- - - - Medicare Primary
AMT*D*67~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Paid                       67.00
AMT*F2*80~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Patient Resp. 80.00
DMG*D8*19470920*F~
OI***Y*S**Y~
NM1*IL*1*MEMBER*IMA*T***MI*123456789A~
NM1*PR*2*MEDICARE PART B*****PI*MEDICARE PAYER ID~
SBR*S*18*9999*AARP MEDIGAP*C1****CI~- - - - - - - - - - - - - AARP Secondary
AMT*D*20~- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AARP Paid 20.00
AMT*F2*60~- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AARP Patient Resp. 60.00
DMG*D8*19470920*F~
OI***Y*S**Y~
NM1*IL*1*MEMBER*IMA*T***MI*123456789~
NM1*PR*2*AARP*****PI* AARP PAYER ID~ __________________________________________________________________________________________

LX*1~
SV1*HC:99214*140*UN*1***1~ - - - - - - - - - - - - - - - - - - - - Charge Line 1 140.00
DTP*472*D8*20030701~
REF*6R*1234~
SVD* MEDICARE PAYER ID*36*HC:99214**1~ - - - - - - - - - - - - -Medicare Paid 36.00
CAS*CO*45*45*1~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Write-off 45.00
CAS*PR*2*9**1*50*1~ - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Coinsurance 9.00
                                      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Deductible 50.00
DTP*573*D8*20030715~- - - - - - - - - - - - - - - - - - - - -Medicare Adjudication Date - - Total $140.00
SVD* AARP PAYER ID*9*HC:99214**1~- - - - - - - - - - - - - - -- AARP Paid (Coins) 9.00
CAS*CO*45*45*1*23*36~- - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Write-off 45.00
                                          - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Paid 36.00
CAS*PR*1*50~- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AARP Deductible 50.00
DTP*573*D8*20030720~ - - - - - - - - - - - - - - - - - - - -AARP Adjudication Date - - - Total $140.00

__________________________________________________________________________________________

LX*2~
SV1*HC:81002*16*UN*1***1~- - - - - - - - - - - - - - - - - - - - - Charge Line 2 16.00
DTP*472*D8*20030701~
REF*6R*1235~
SVD* MEDICARE PAYER ID*12*HC:81002**1~ - - - - - - - - - - Medicare Paid 12.00
CAS*CO*45*4~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Write-off 4.00
DTP*573*D8*20030715~ - - - - - - - - - - - - - - - - - - - - -Medicare Adjudication Date - - -Total $16.00
SVD* AARP PAYER ID*0*HC:81002**1~- - - - - - - - - - - - - - - - AARP Paid (No Balance) 0.00
CAS*CO*45*4*23*12~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Write-off 4.00
                                      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Paid 12.00
DTP*573*D8*20030720~ - - - - - - - - - - - - - - - - - - - - - -AARP Adjudication Date - - - -Total $16.00
__________________________________________________________________________________________
LX*3~
SV1*HC:74241*76*UN*1***1~ - - - - - - - - - - - - - - - - - - - - - Charge Line 3 76.00
DTP*472*D8*20030701~
REF*6R*1236~
SVD*MEDICARE PAYER ID*15*HC:74241**1~- - - - - - - - - - Medicare Paid 15.00
CAS*CO*45*41~- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Write-off 41.00
CAS*PR*2*10**1*10~-- - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Coinsurance 10.00
                                    - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - Medicare Deductible 10.00 DTP*573*D8*20030715~- - - - - - - - - - - - - - - - - - - - - - - - - -Medicare Adjudication Date - - - Total $76.00
SVD* AARP PAYER ID*10*HC:74241**1~ - - - - - - - - - - - - - - AARP Paid (Coins) 10.00
CAS*CO*45*41*23*15~ - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Write-off 41.00
                                      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Paid 15.00
CAS*PR*1*10*~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AARP Deductible 10.00
DTP*573*D8*20030720~- - - - - - - - - - - - - - - - - - - - - - - - - -AARP Adjudication Date - - - - - Total $76.00 _________________________________________________________________________________________

LX*4~
SV1*HC:36415*7*UN*1***1~ - - - - - - - - - - - - - - - - - - - - - - Charge Line 4                             7.00
DTP*472*D8*20030701~
REF*6R*1237~
SVD*MEDICARE PAYER ID* 4*HC:36415**1~ - - - - - - - - - - - Medicare Paid                    4.00
CAS*CO*45*2~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Write-off            2.00
CAS*PR*2*1~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Medicare Coinsurance        1.00
DTP*573*D8*20030715~- - - - - - - - - - - - - - - - - - - - Medicare Adjudication Date - - - -  Total $7.00
SVD*AARP PAYER ID*1*HC:36415**1~ - - - - - - - - - - - - - - - - AARP Paid (Coins)             1.00
CAS*CO*45*2*23*4~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Write-off     2.00
                                  - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Echo Medicare Paid            4.00
DTP*573*D8*20030720~- - - - - - - - - - - - - - - - - - - -AARP Adjudication Date - - - - - - Total $7.00 _______________________________________________________________________________________

SE*83*219091~
GE*1*25781~
IEA*1*000025781~