Secondary Electronic Claims

Introduction

An insured person may have multiple insurance policies which will pay for medical services. These policies are designated as primary, secondary and tertiary.

A “secondary” claim is a claim where the primary, or first insurance company, has adjudicated the claim and responded to the provider with an EOB (explanation of benefits). The provider is requesting payment from the next, or second, insurance carrier. For Medicare Secondary claims, Medicare is the second or next payer, responsible for payment of the remaining unpaid balance of the claim.

Medicare will pay secondary benefits when the following apply:

· the primary payer does not pay the entire charge (and Medicare allowable is more)

- or -

· physician is not obligated to accept primary payment as full payment

In order for secondary claims to processed, they require all the payment information provided by the primary payer on the primary payer’s EOB. Both the claim and service levels have required fields; in addition, the totals of the primary payer’s payments must balance.

Identifying Secondary Claims

You can search for Secondary Claims by using the Resp Payer search option on the Claim Selection part of Claim Manager. The second alpha character in the Type column on the Claim Selection List indicates the type of claim. For all secondary Electronic claims the second character will be S.

When a secondary claim is selected the top bar of the open claim window will display Secondary Claim.

Claim-Level Subscriber and Coordination of Benefits (COB) Information

Medicare-as-Secondary Information

All secondary fields are available for manual entry or update in the application. To access the Secondary Claim Information click on the Misc Button on the Claim Edit screen.

Resp Payer: The responsible payer must be shown as Secondary. This is determined based on the file types and fields shown above.

The inbound file must have the following information for a claim to be loaded as secondary:

ANSI Loop 2000B Subscriber Information, SBR01 = S

NSF DA02 = 02 (sequence order is 2), DA04 = I

HCFA Box 11D = Y

Also, in an ANSI file, the Other Subscriber information in Loop 2330A, SBR01 must equal “P”.

Filing Indicator: The filing indicator must be MB for Medicare Part B.

Loop 2000B Subscriber Info, SBR09 = MB

Medicare Secondary: The Medicare secondary filing code is the reason that Medicare is the secondary payer. This must be a valid Medicare reason

This inbounds in Loop 2000B Subscriber Info, SBR05.

Primary Payer Payment Information (COB)

Payments and other details of the primary payer’s COB data are found on the Insurance 2 button of the Claim Edit Screen. When you click on the Insurance 2 button, you will the primary payer’s information as it was received on an inbound claim.

Second Insurance Information

Keep in mind that when a claim is secondary, the second insurance information will be the primary insurance company’s information. The payer we are requesting payment from is the payer one on this claim, and the payer who has already paid is the second payer on this claim. Don’t be confused by the “2” in the button name – you want to report the primary payer’s information in these fields because they are the second insurance being reported when this claim is filed.

Payer Name: The name of the primary payer.

Loop 2330B Other Payer Name NM103

Resp Level: The responsibility level for this payer – must be Primary.

Loop 2320 Other Subscriber Info, SBR01 = P

Insurance Type: Indicates the type of primary policy the subscriber holds.

Loop 2320B Other Subscriber Info, SBR05

Payer ID Type: The qualifier for the primary payer’s subscriber number. Payer ID Type should be PI for “Payer ID”

Loop 2330B Other Payer Type, NM108

Payer ID: The electronic payer id assigned to the primary payer

Loop 2330B Other Payer, NM109

Note: This ID must match the payer id reported at the service-line.

Payer Type: The type of primary insurance plan.

Loop 2320 Other Subscriber Info, SBR09

COB Information

From the Insurance 2 screen, you will click on the COB Information button, which gives you access to the detail of claim-level primary information.

When you click on the button, you will see the primary payer’s claim-level payment information.

Paid*: The total amount paid by the primary payer for this claim.

Loop 2320 Other Subscriber Information, AMT*D*

Note: The sum of each service-line primary-paid must equal this amount.

Allowed*: The total amount allowed for this claim by the primary payer.

Loop 2320 Other Subscriber Information, AMT*B6*

Note: The sum of each service-line primary allowed must equal this amount.

Adjud Date*: The adjudication is the date the payer completed the review of this claim and determined its status. This is the Check Date on the EOB.

Loop 2330B Other Payer Information, DTP*573*

Other Fields: You may have other primary payment information to report at the claim level. The available fields are displayed above.

Note: Any adjustments entered here will be included in the claim-level balancing required by Medicare.

Payment Adjustments

Insurance Payers use Claim Adjustment Group and Reason codes to report the reason the full amount of a charge was not paid. These amounts are referred to as payment adjustments. Payment adjustments include Patient deductibles, co-insurance amounts, contractual write-offs, etc. If the primary insurance company did not pay the full amount of the charge, CAS segments are used to report the amount of the payment adjustment and the reason code to the secondary insurance company. The Primary Insurance Payor will determine if payment adjustments occur at the Claim Level and/or the Service-Line Level. Most insurance companies report Payment Adjustments and the Claim Adjustment and Reason Codes at the Service-Line Level. It is important to note that the payment adjustments should be reported at the level they are reported on the EOB. If an adjustment is reported at the service-line level IT SHOULD NOT BE reported at the claim level and vice-versa.

Claim Adjustment Codes

Claim Adjustment Group Codes is a group code that is used to categorize the payment adjustment code. An official list of group codes can be found at Washington Publishing Company’s website at http://www.wpc-edi.com/content/view/701/397/. The Claim Adjustment Reason code gives the specific descriptions of the payment adjustment code. A complete list of Claim Adjustment Reason Codes is available for viewing on the Washington Publishing Company’s website: http://www.wpc-edi.com/content/view/695/1 .

Claim Level Adjustments (CAS Segments)

The fields needed to enter Claim Level Adjustments are located on the Other Payer COB window.

Select The Claim Adjustment Group code that the payment adjustment belongs to. Once selected click New button to enter the Claim Adjustment Reason code and the dollar amount in the Claim Level Adjustments window.

All Claim Level Adjustments Report in Loop 2320 Other Subscriber Information

Contractual Obligations: CAS*CO*Code*Amount

Patient Responsibility: CAS*PR*Code*Amount

Corrections and Reversals: CAS*CR*Code*Amount

Other Adjustment: CAS*OA*Code*Amount

Payer Initiated Reductions: CAS*PI*Code*Amount

Service-Level COB Information

Medicare requires primary payer data at the service level of a secondary claim, as well as at the claim level. You can access Service Level information on an open claim by double-clicking the service line. You will then see a button in the COB Information on bottom right-hand side of the screen.

When you click on this button, you will have access to the service-level COB fields.

Payer ID*: The 5-character EDI payer code assigned to the primary payer of this service.

Loop 2430 Line Adjudication Information, SVD01

Note: The payer id must match the id entered at the claim-level.

Paid*: The amount the primary payer paid on this service.

Loop 2430 Line Adjudication Information, SVD02

Note: This amount will be included in the total paid for this claim.

Quantity*: The quantity of this service.

Loop 2430 Line Adjudication Information, SVD05

Procedure Type*: The qualifier or type of procedure for this service.

Loop 2430 Line Adjudication Information, SVD03:1

Procedure Code*: The CPT code for this service.

Loop 2430 Line Adjudication Information, SVD03:2

Approved*: The amount the primary payer approved for this service.

Loop 2400 Service Line Information, AAE*

Note: This amount will be included in the approved total for this claim.

Adjud Date*: Adjudication Date; the date of the COB payment of the primary payer of this service.

Loop 2430 Line Adjudication Information, DTP*573

Service Level Adjustments (CAS Segments)

The fields needed to report payment adjustments at the Service Level are located on the Transaction COB Screen. As was mentioned if a payment adjustment was entered at the Claim Level then it does not need to be entered at the Service Level. If the same adjustment is entered at both the Claim and Service Level then the claim will be invalid for balancing issues.

All Claim Level Adjustments Report in Loop 2430 Line Adjudication Information

Contractual Obligation: CAS*CO*Code*Amount

Corrections and Reversals: CAS*CR*Code*Amount

Other Adjustments: CAS*OA*Code*Amount

Payer Initiated Reductions: CAS*PI*Code*Amount

Patient Responsibility: CAS*PR*Code*Amount

Manual Entry

If a customer is required to enter all of this information manually, he/she can click the Load Defaults button. The software will load the known information from the inbound file: primary payer’s payer id, procedure code, procedure type, quantity, and modifiers.

Balancing Requirements

For claims with Medicare as secondary payer (MSP), the following are requirements for a claim to pass Medicare edits:

Claim Primary Paid Amount

The Sum of all line items payment amount (SVD02)=Claim’s Primary Payment Amount (AMT*D)

Claim Primary Payer Allowed Amount

The sum of all line items approved amount (AMT*AAE)=Claim’s Primary Payer Allowed Amount (AMT*B6)

Medicare Error Message: M195

Total Claim Charge Amount

The Primary Paid Amount (AMT*D)+ Claim Level Adjustments (CAS segments) + Line Level Adjustments (CAS segments)= Claim Amount (CLM02)

Medicare Error Message: M384

Line Item Charge Amount

Line Item Primary Paid Amount (SVD02)+Line Level Adjustment (CAS Segment)=Line Item Charge Amount (SV102)

Medicare Error Message: M194

Secondary COB Balancing Summary

The Secondary COB Balancing Summary can be used to determine why a secondary claim is out of balance. The report can be accessed by highlighting the claim and click the c key.

The Secondary COB Balancing Summary will list each transaction that has been reported on the claim. The Line Item Information will allow you to see what is being reported at the line item level. Line Items that are not in Balance will be listed as Not Equal To.

The bottom section of the Secondary COB Balancing Summary Reviews the 4 Basic Balancing Edits. If the claim does not meet one of the Balancing Edit criteria then the transaction will be listed as Not Equal To.

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