Coordination of Benefits Standard v3.2

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UHIN Standard 5010 837 Coordination of Benefits is compatible with all HIPAA requirements.

Purpose: The purpose of this Standard is to streamline the coordination of benefits process between payers and providers or payer to payers. The over all goal of this standard is to define the data to be exchanged for Coordination of Benefits (COB) and increase effective communications.

Applicability: This standard applies to both payers and providers that pay and bill electronic claims in the State of Utah. These requirements are intended to outline the creation of a coordination of benefits claim.

Detail:

In order for COB to be sent in an electronic format the provider must accept electronic Remittance Advice (835 Electronic Remittance Advice v5010) from the primary payer or be able to convert paper remittance data into the proper ANSI reason codes necessary to send a HIPAA compliant electronic COB claim (837 Health Care Claim/Encounter v5010).

The following tables are included to assist providers and payers in understanding how to report remittance advice data (835) from a primary payer to a secondary payer. It is preferred that data be reported at the same level in the Coordination of Benefit claim (837) that it is received in the remittance advice (835).

 

Elements for providers submitting a secondary institutional claim report at claim level

All adjustments that are reported on the 835 must be sent in the secondary claim in the 837.

Data element

X12 Mapping to the 837 Institutional Claim

Mapping from the 835

Comments

Total Claim Charge Amount

Loop 2300 CLM02

Loop 2100 CLP03

The original total charges.

Patient Responsibility

2320 AMT AMT02

When the AMT01=EAF

Loop 2320 CAS CAS03/06/09/12/15/18

Loop 2100 CLP05

Loop 2100 CAS

03/06/09/12/15/18

This would include all Claim adjustments identified with the “PR” Claim Adjustment Group Code in the CAS Segment.

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Discount amounts

Loop 2320 CAS CAS03/06/09/12/15/18

Loop 2100 CAS CAS03/06/09/12/15

See Appendix A for appropriate Claim adjustment Group Codes

 Should be reflected in the CAS segment as an adjustment for those payers that the provider is required to accept the adjustment.

Coordination of Benefits Total Non- Covered  Loop 2320 AMT02 When AMT01=A8    This element is used for reporting a total dollar amount that has not been billed to a primary payer because the primary payer has no benefits for this service.  The secondary payer may require the denial from the primary payer.
Claim Check or Remittance Date  

Loop 2330B DTP03

When DTP01=573 and Loop 2430 is not used.

 

Situational Header DTM02

When DTM 01 = 405

 This is the end date for the adjudication production cycle for the claim included in the 835.
Coordination of Benefits - Payer Paid Amount  Loop 2320 AMT02 When AMT01= D  Loop 2100 CLP04  This amount is the actual dollar amount that the provider received as payment.

 

Elements for providers submitting a secondary institutional claim for service line level

All adjustments that are reported on the 835 must be sent in the secondary claim in the 837.

Data element

X12 Mapping to the 837 Institutional Claim

Mapping from the 835

Comments

Total Claim Charge Amount

Loop 2300 CLM02

Loop 2100 CLP03

The Claim Charge Amount is a total of line item charge amounts.

Line Item Charge Amount

2400

SV203

Loop 2110 SVC02

 

Patient Responsibility

2430 AMT AMT02

When the AMT01=EAF

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15

This would include all Claim adjustments identified with the “PR” Claim Adjustment Group Code in the CAS Segment.

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Discount amounts

Loop 2430 CAS CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Should be reflected in the CAS segment as an adjustment for those payers that the provider is required to accept the adjustment.

Line Check or Remittance Date

Loop 2430 DTP03 When DTP01 = 573

and 2330B is not used

Situational Header DTM02

When DTM 01 = 405

This is the end date for the adjudication production cycle for the claim included in the 835.

Non-Covered

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Report as received on the 835 as appropriate.

Service Line Paid Amount

Loop 2430 SVD02

Loop 2110 SVC03

This amount is the actual dollar amount that the provider received as payment.

 

Elements for providers submitting a secondary professional claim at claim level

 Data element

X12 Mapping to the 837 Professional Claim

Mapping from the 835

Comments

Total Claim Charge Amount

Loop 2300 CLM02

Loop 2100 CLP03

The original total charges

Patient Responsibility

2320 AMT AMT02

When the AMT01=EAF

Loop 2100 CLP05

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Loop 2320 CAS03/06/09/12/15/18

Loop 2100 CAS03/06/09/12/15/18

In this case the payer would use the “PR” Claim Adjustment Group Code

Discount amounts

Loop 2320 CAS03/06/09/12/15/18

Loop 2100 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Should be reflected in the CAS segment as an adjustment for those payers that the provider is required to accept the adjustment.

Coordination of Benefits Total Non- Covered

Loop 2320 AMT02 When AMT01=A8

 

This is a new element that is used for reporting a total dollar amount that has not been billed to a primary payer because the primary payer has no benefits for this service.  The secondary payer may require the denial from the primary payer.

Claim Check or Remittance Date

Loop 2330B DTP03

When DTP01=573 and Loop 2430 is not used.

Situational Header DTM02

When DTM 01 = 405

This is the end date for the adjudication production cycle for the claim included in the 835.

Coordination of Benefits – Payer Paid Amount

Loop 2320 AMT02 When AMT01=D

Loop 2100 CLP04

This amount is the actual dollar amount that the provider received as payment.

 

Elements for providers submitting a secondary professional claim at line level

Data element

X12 Mapping to the 837 Professional Claim

Mapping from the 835

Comments

Line Item Charge Amount

Loop 2400 SV102

Loop 2110 SVC02

The original total charges.

Patient Responsibility

2430 AMT AMT02

When the AMT01=EAF

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

In this case the payer would use the “PR” Claim Adjustment Group Code

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Discount amounts

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Should be reflected in the CAS segment as an adjustment for those payers that the provider is required to accept the adjustment.

Non-Covered

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Report as received on the 835 as appropriate.

Line Check or Remittance Date

Loop 2430 DTP03

When DTP01 = 573

and 2330B is not used

Situational Header DTM02

When DTM 01 = 405

This is the end date for the adjudication production cycle for the claim included in the 835.

Service Line Paid Amount

Loop 2430 SVD02

Loop 2110 SVC03

This amount is the actual dollar amount that the provider received as payment.

 

Elements for providers submitting a secondary dental claim at claim level

Data element

X12 Mapping to the 837 Dental Claim

Mapping from the 835

Comments

Total Claim Charge Amount

Loop 2300 CLM02

Loop 2100 CLP03

Total Original Charges.

Patient Responsibility

2320 AMT AMT02

When the AMT01=EAF

Loop 2320 CAS03/06/09/12/15/18

Loop 2100 CLP05

Loop 2100 CAS03/06/09/12/15/18

In this case the payer would use the “PR” Claim Adjustment Group Code

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Coordination of Benefits Total Non- Covered

Loop 2320 AMT02 When AMT01=A8

 

This is a new element that is used for reporting a total dollar amount that has not been billed to a primary payer because the primary payer has no benefits for this service. The secondary payer may require the denial from the primary payer.

Claim Check or Remittance Date

Loop 2330B DTP03

When DTP01=573 and Loop 2430 is not used.

Situational Header DTM02

When DTM 01 = 405

This is the end date for the adjudication production cycle for the claim included in the 835.

Coordination of Benefits – Payer Paid Amount

Loop 2320 AMT02 When AMT01=D

Loop 2100 CLP04

This amount is the actual dollar amount that the provider received as payment.

 

Elements for providers submitting a secondary dental claim at line level  Dental claims are usually paid at the line level for most lines of business and programs.  Payers that participate with UHIN request that the following elements at the line level be submitted for processing Coordination of Benefits.

Data element

X12 Mapping to the 837 Dental Claim

Mapping from the 835

Comments

Line Item Charge Amount

Loop 2400 SV302

Loop 2110 SVC02

The original total charges.

Patient Responsibility

2430 AMT AMT02

When the AMT01=EAF

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

In this case the payer would use the “PR” Claim Adjustment Group Code

EAF is used by providers when they disagree with the prior payer reporting of patient responsibility.

Required. Report exactly as received from 835. The total Patient Responsibility would be the sum of all CAS amounts identified with a PR Group code.

Discount amounts

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Should be reflected in the CAS segment as an adjustment for those payers that the provider is required to accept the adjustment.

Non-Covered

Loop 2430 CAS03/06/09/12/15/18

Loop 2110 CAS03/06/09/12/15/18

See Appendix A for appropriate Claim adjustment Group Codes

Report as received on the 835 as appropriate.

Line Check or Remittance Date

Loop 2430 DTP03 When DTP01 = 573

and 2330B is not used

Situational Header DTM02

When DTM 01 = 405

This is the end date for the adjudication production cycle for the claim included in the 835.

Service Line Paid amount

Loop 2430 SVD02

Loop 2110 SVC03

This amount is the actual dollar amount that the provider received as payment.

 

Tertiary Billing

When billing Tertiary, use all applicable COB loops for each payer. This requires repeating certain COB loops and allows the sender to communicate the dollar amounts for each payer in a separate loop.

COB Loops:

Loop ID-2320 contains the following:

  • claim level adjustments
  • other subscriber demographics
  • various amounts
  • other payer information
  • assignment of benefits indicator
  • patient signature indicator

Loop ID – 2330

  • Other Subscriber Information
  • Other Payer Information

Loop ID-2430 contains the following:

  • ID of the payer who adjudicated the service line
  • amount paid for the service line
  • procedure code upon which adjudication of the service line was based – this code may be different than the submitted procedure (This procedure code also can be used for unbundling or bundling service lines.)
  • paid units of service
  • service line level adjustments
  • adjudication date

Example - Sending the Claim to the Third Destination Payer:

2000B/2010BB Third payer 2000B – Subscriber SBR01 = T

2010BB – Payer Name

NM103 = Destination Payer Name 2320/2330 Primary payer

2320 – Other Subscriber - Claim Level COB SBR01 = P

CAS* segments

CAS claim level amounts are cross walked from the primary payer’s 835 or paper RA.

2330A – Other Subscriber

NM1* = Other Subscriber Name 2330B – Other Payer

NM1* = Previous Payer Name 2430 Primary payer

2430 – Line Adjudication – Line Level COB CAS* segments

CAS line level amounts are cross walked from the primary payer’s 835 or paper RA.

DTP03 = Payment or Adjudication Date

2320/2330 Secondary payer (repeat 2320/2330 loops as needed for additional payers.)

2320 – Other Subscriber - Claim Level COB

SBR01 = S

CAS* segments

CAS claim level amounts are cross walked from the primary payer’s 835 or paper RA.

2330A – Other Subscriber

NM1* = Other Subscriber Name 2330B – Other Payer

NM1* = Previous Payer Name 2430 Secondary payer

2430 – Line Adjudication – Line Level COB CAS* segments

CAS line level amounts are cross walked from the primary payer’s 835 or paper RA.

DTP03 = Payment or Adjudication Date

Repeat as necessary up to a maximum of 10 times. Any one claim can report a total of 11 payers (10 carried at the COB level and 1 carried up at the top 2010BB loop).

 

Implementation Issues:

  1. UHIN Payers will accept Coordination of Benefits claims if providers can supply the required
  2. When a previous payer clinically edits the claim and adjudicates under a procedure code different from the originally submitted code, then the provider must submit original billed procedure code plus the code the payer paid See section 1.4.1.4 in the 5010 TR3 (Implementation Guides)
  3. If a provider is non contracted and the prior payer reports a discount item this amount may be included as patient
  4. Allowed/Approved Amount data segments were removed from the 5010 Implementation Guides. If a payer needs these amounts for adjudication then they must be calculated using data sent in the claim. For calculation methods see WEDI 837 Coordination of Benefits Deleted AMT Segments Brief.
  5. There are instances where the provider may send a code on line of service to the primary payer and the secondary payer requires a different In this instance when the provider sends the secondary payers required code this is not considered fraudulent billing.
  6. A recommended reference for Coordination of Benefit business use is the WEDI HIPAA Coordination of Benefits White paper which can be found on the WEDI web site at wedi.org.
  7. When a provider receives a Claim Adjustment Reason Group Code “Payer Initiated - PI” the claim should not be sent to the secondary payer until the provider has worked with the payer to resolve any unresolved issues before sending to the secondary

This code is generally used for clinical editing where the claim has been submitted by a non- contracted provider. In this instance, once the provider has resolved all outstanding issues with the previous payer:

  • If the patient is considered not responsible the code may need to be changed to “Contractual Obligation – CO” for the secondary
  • If the patient is considered responsible the code may need to be changed to “Patient Responsibility – PR” for the secondary
  • Depending upon the determination of the negotiations with the previous payer the code could also be sent as it was
  1. Subsequent Payers may choose to deny the claim due to what appears to be non-compliance of previous payer plan It is strongly recommended that providers work with each payer to ensure all plan requirements are met for completed processing prior to sending a COB claim to the next payer. The following codes have been identified for denying the claim when a previous payer’s plan requirements have not been met.

The following table shows examples of how the codes included in the above Standard may be used. This table further illustrates the flow of code usage from Remittance Advice to a Secondary Claim and Secondary Payer.

TABLE I

Scenario secondary payer

Primary Payer 835

Secondary 837 Claim COB Segment

Secondary Payer 835

Denied for additional information from Subscriber

OA 227*

(Other payers deny using PR)

*This may result in the provider billing the patient

OA 227

OA 228

Denied for additional information from Par Provider

– Billing/Rendering

CO 226

CO 226

OA 228

Denied for additional information from Par Provider

– Other

CO 148

CO 148

OA 228

Denied for additional information from Non Par Provider – Billing/Rendering

PI 226

PI 226

OA 228

Denied for additional information from Non Par Provider – Other

PI 148

PI 148

OA 228

148 Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

  • Information requested information from billing/rendering provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason )
  • Information requested information from patient/subscriber/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason )
  • Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their
  1. It is recommended that payers consider adding ANSI reason codes in the paper explanation of benefits description or begin using ANSI codes in lieu of proprietary
  2. Implementation Time line: This COB Standard must be implemented with the 5010 UHIN implementation of the ASC x12 837 Claim/Encounter Transaction, October
  3. COB Examples can be found in a separate document titled:

Coordination of Benefits – Reporting Use Cases

Click HERE to be taken to the document

 

History: (MM/DD/YY)

 

Original

A* 1

V3

3.1

3.2

ORIGINATION DATE

12/03/04

1/2008

02/23/2010

8/13/2014

3/2016

APPROVAL DATE

6/2006

05/15/09

11/3/2010

9/10/2014

11/2016

EFFECTIVE DATE

7/2006

06/15/09

12/3/2010

11/5/2014

11/2/2016

* A = Amendment

 

Appendix A - Definitions

There are five Claim Adjustment Group Codes that Payers can use to identify the type of adjustment being reported1. They are:

CO Contractual Obligations

Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.

This group code should be used when a contractual agreement between the payer and payee, or regulatory requirement, resulted in an adjustment. Generally these adjustments are considered a write off for the provider and are not billed to the patient.

 

CR Correction and Reversals

Use this code for corrections and reversals to PRIOR claims. Use when CLP02=22, reversal of previous payment, all CAS01 elements must equal the CR.

This group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim. When correcting a prior claim, CLP02 (claim status code) needs to be 22. See ASC X12N Health Care Payment/Advice Implementation Guide (835 for complete information about corrections and reversals. This code is still valid for 5010 claims (837) but is not a part of the electronic remittance advice (835), it may still be in use as a transition hold over for any COB claims.

 

OA Other Adjustments

Avoid using the Other Adjustment Group Code (OA) except for business situations described in the front matter of this guide.

This group code should be used when no other group code applies to the adjustment

 

PI Payor Initiated Reductions

Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e. medical review or professional review organization adjustments).

 

PR Patient Responsibility

This Amount can include, but is not limited to such items as deductible, non- covered services, co-pay, and co-insurance.

1 The first description of the codes was copied from the ASCX12 Health Care Payment/Advice Payment Advice Implementation Guide. The italicized description was taken from the Explanation of Claim Adjustment Group Code FAQ listed on the Washington Publishing web site.

This group code should be used when the adjustment represents an amount that should be billed to the patient or insured.  This group code would typically be used for deductible and copay adjustments

 

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