In a Coordination of Benefits (COB) claim, the 837 Implementation Guide requires the CAS segment to be sent if the prior payer reported one or more adjustments and their adjudication was reported in an 835 transaction. However, because the prior payer’s adjustments are used by NYSDOH in determining appropriate payment, any prior payer’s adjustments, whether reported on an 835 or on paper, must be sent to assure proper payment. The information sent in the Coordination of Benefits claim should accurately and fully report what was sent by the prior payer, and should be reported on the same level (line or claim).

The maximum that a secondary payer considers for payment is the Total Claim Charge Amount in CLM02 minus the sum of all prior payer payments. In almost all cases, the secondary payer will not consider any amount that was billed that exceeds the primary payer's allowable / approved amount for a covered service.

If the prior payer did not make a payment their remittance advice will still show total adjustments equal to the amounts charged.

Note: see the FAQ on “Zero Fill” for more information.