NYS Medicaid has responded to numerous questions both internally and externally regarding COB claiming. This document is submitted as a step toward consolidating some of the FAQ's and other documents that have been written on the subject. Hopefully, the consolidation and refinement of this information will eventually aid customer service as well as providers who may benefit from additional visual examples as a learning tool. In order to set up our example, it is important to understand the initial claim and how a typical primary payer may respond to the provider; so this document contains a basic example of a professional claim and a paper remit/EOB.
NYS Medicaid has received inquiries concerning the process for providing NYS Medicaid the necessary prior payer adjudication information when the provider did not receive an electronic, 835 remittance from the prior payer. There is language from NYS Medicaid stating that we need exact information provided in the prior payer's 835 (that is true,) but our example should emphasize that a proper COB 837 can be built from information received by the provider from a paper remit or explanation of benefits from the prior payer.
In our example, a claim with four line items or procedures is being billed to Medicare. Not withstanding all the other information on a claim, it is interesting that basically from two pieces of information, (the procedure code and the charge) the provider received up to five additional data elements (dollar amount values) that should be provided to the next payer - in this case, NYS Medicaid.
Sample claim to be used throughout the upcoming example:
The following example 837P claim will serve for the remainder of this document. (For the purposes of this example, the procedure codes are actual valid codes, but no other representation has been made about the associated charges, nor payments, nor any coinsurance or deductible schemes. The example claim only exists so that the reader can follow the values through the building of the X12 claim.)
In this example, Medicare processes the claim and responds to the provider on a paper remit. Below is a typical (generic) Medicare paper remit. The provider must now bill Medicaid for the balance of the claim with all the new detail provided by Medicare. In the claim below, Medicaid will be billed for $80 – the sum of the patient’s Medicare Deductible and Coinsurance (shown in the last 2 columns.)
Build an 837P COB claim with 2400 line level detail information:
For this example, we will go straight to the line level and discuss how the charges, payments and adjustments (the remit data) should be entered. First, Loop 2400 Service Line is required. In our example, we have four lines (four service lines due to four procedures.) We will describe one of those lines.
The first charge, $140.00, resides at SV102. The DTP segment contains the date of service and the following REF segment contains the provider’s line item reference number that gets reported back on NYS Medicaid’s 835.
LX*1~
SV1*HC:99214*140*UN*1***1~
DTP*472*D8*20030701~
REF*6R1234~
Loop 2430 Line Adjudication Information contains the detail COB prior payer payment and adjustment information. The 2430 SVD Line Adjudication Information segment contains the prior payer’s payment. The 2430 CAS Line Adjustment segment(s) warrant some additional discussion.
SVD*MEDICARE PAYER ID*36*HC:99214**1~
CAS*CO*45*45~
CAS*PR*2*9**1*50~
DTP*573*D8*20030715~
The 2430 CAS Line Adjustment segment is used to report any adjustments to the line charge, which caused the line amount paid to differ from the amount originally charged. The segment will reflect reductions for patient responsibility i.e., coinsurance, deductible, co-pay, etc. and also can reflect full patient responsibilities if the service line charge is for a service that was not covered by the payer being reported on. In addition, reduction to the charge is reported in this segment for contractual obligation that reduces the charge to the allowed maximum reimbursable amount agreed upon between the provider and the payer.
In our example, Medicare allowed $95 on a $140 charge creating a Contractual Obligation write-off/adjustment of $45, which is shown in the first CAS segment. The CAS segment requires identification of the “Group Code”, “Claim Adjustment Reason Code” and either a monetary amount and/or number of units being adjusted. Back to our example, our first CAS segment shows a Group Code of CO (Contractual Obligation), a Claim Adjustment Reason Code of 45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.) followed by the dollar amount $45.00.
The second CAS segment contains the two Patient Responsibility values from the paper remit. This CAS segment shows a Group Code CAS01 of PR (Patient Responsibility), a Claim Adjustment Reason Code CAS02 of 2 (Coinsurance Amount,) followed by the dollar amount $9.00 in CAS03. The other PR amount reported in the same CAS segment is the Deductible. The Claim Adjustment Reason Code CAS05 is 1 (Deductible Amount) and the dollar amount in CAS06 is $50.00
SVD*MEDICARE PAYER ID*36*HC:99214**1~
CAS*CO*45*45~
CAS*PR*2*9**1*50~
DTP*573*D8*20030715~
Balancing – All the dollar amounts have been discussed; the claim must be mathematically sound beginning here at the 2400 level. In order to balance at this level, the line level payments and adjustments must add up to the line level charge. The 2430 CAS adjustment values plus the 2430 SVD02 payment value must equal the 2400 SV102 charge just as the Medicare Dis-allowed ($45), Medicare Pay ($36), Medicare Deductible ($50), and Medicare Coinsurance ($9) amounts equaled the Provider’s charge ($140) on the paper remit. Of course, the total claim charge resides in the 2300 CLM Claim Information segment seen below. When totaled, (and in order to balance) all the SV102 charge amounts should equal the claim level charge in the 2300 CLM02 displayed below.
CLM*PATIENT001*239***11::1*Y*A*Y*Y*B******P~
The 2320 SBR Other Subscriber Information segment, which pertains to the policyholder whose insurance coverage made payment for the patient, must indicate whether the payer is primary, secondary, etc, in the SBR01, the relationship code in SBR02, and the claim filing indicator code in the SBR09 – in our case, the SBR09 is MB for Medicare Part B
SBR*P*18*******MB~
The 2320 AMT Prior Payer Amount segment should contain the total amount of payment received from the payer being reported even though the payments are also being reported at the 2430 SVD Line Adjudication segment. The 2320 AMT is reported using qualifier D when filing an 837 Professional or Dental claim or C4 when filing the 837 Institutional claim.
AMT*D*67 ~
The 2320 DMG Subscriber Demographic Information segment is syntactically required and must be present as is the 2320 OI Other Insurance Coverage Information segment. This information must be submitted to pass front end edits even though NYS Medicaid will ignore.
DMG*D8*19200305*F~
OI***Y*S**Y~
NYS Medicaid also expects at a minimum, for syntax editing purposes, Loop 2330B Other Payer Name identifying the payer whose information is contained in 2320 Loop. Loop 2330B Other Payer Name, NM1 segment is required and would be represented as Medicare Part B in our example. (Other information contained in Loop 2330A Other Subscriber Name is always situational and NYS Medicaid will not edit this information if submitted. Syntactically the information need not be present , but if present, must be HIPAA compliant.) Below, is the 2330B NM1 Other Payer Name segment. 2430 SVD01 must equal 2330B NM109 .
NM1*PR*2*MEDICARE PART B*****PI*MEDICARE PAYER ID~
Now, we should view the whole claim – the COB portions.
Values from the paper remit shown in the COB 837P claim to Medicaid:
All detail from remit shown at 2400 Line Level. Medicaid still needs the 2320 AMT (total prior payer paid) even though the detail payments reside at the 2400 level.
