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Edit 00131
Third Party Indicated/Other Insurance AMT Not Submitted
HIPAA Claim Adjustment Reason Code: 22
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 85
Entity Identifier Code: MR
Potential Causes:
The patient has TPL (Third Party Liability) coverage on file in the eMedNY system, but the claim does not include payment information from the TPL payer.
Solution:
Confirm that the claim has been billed to the TPL payer and a remittance advice has been received. The adjudication information from the remittance advice must be reported in the Coordination of Benefits claim to NYS Medicaid.
Please enter your prior payer information in either the Claim Level or Service Level segments of the 837 transaction. Note: NYSDOH will process Medicare or other insurance information as received by the submitter in a Remittance Advice. Any adjustment amount from one adjustment should be reported only once. Please do not repeat a claim level adjustment at the line level. Furthermore, do not report the total of the line level adjustments in a claim level CAS segment.
However, if it is known that the TPL payer does not cover these services, or if they paid zero due to adjustments refer to the following FAQ posted on nyhipaadesk.com.
Zero Fill or 0FILL - What is the 0FILL plan that is referenced in the 837 Companion Guides?
Enter the appropriate Third Party Liability adjudication information in the following locations and resubmit.
| 837 Institutional, 837 Professional, and 837 Dental (Claim Level) |
Loop 2000B, SBR (Subscriber Information)
SBR04 = 0FILL or MEDICAID (Group or Plan Name)
SBR09 = Claim Filing Indicator Code
Loop 2320, CAS (Claim Level Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 3 (copayment) (Adjustment Reason Code)
CAS03 = Deductible/Copayment Amounts (Adjustment Amount)
If both Deductible and Copayment were applied CAS05 and CAS06 must also be sent. CAS04, which is often not populated, must still be indicated with a delimiter.
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Amount paid by TPL payer (Other Patient Payer Paid Amount)
Loop 2330B, NM1 (Other Payer Name)
NM109 = Payer Code from Other Payer (Other Payer Primary Identifier)
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| 837 Institutional, 837 Professional, and 837 Dental (Line Level) |
Loop 2000B, SBR (Subscriber Information)
SBR04 = 0FILL or MEDICAID (Group or Plan Name)
SBR09 = Claim Filing Indicator Code
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Amount paid by TPL payer (Other Patient Payer Paid Amount)
Loop 2330B, NM1 (Other Payer Name)
NM109 = Payer Code from Other Payer (Other Payer Primary Identifier)
Loop 2430, SVD (Service Line Adjudication Information)
SVD01 = Same Code Entered in Loop 2330B NM109 (Payer Identifier)
SVD02 = Amount Paid by Medicare (Service Line Paid Amount)
Loop 2430, CAS (Service Line Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 3 (copayment) (Adjustment Reason Code)
CAS03 = Deductible/Copayment Amounts (Adjustment Amount)
If both Deductible and Copayment were applied CAS05 and CAS06 must also be sent. CAS04, which is often not populated, must still be indicated with a delimiter.
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