The Validator was designed specifically to address
the issue of sending PRIMARY insurance claims to any carrier who accepts
a HIPAA compliant form file. That being said, while the Validator
was not designed specifically to send Secondary claims, and the required
coordination of benefits information, there have been some clients
who have specifically requested this ability.
Not being a company to shy away from offering what others will not,
Stephens & Associates has developed several ways in which you
can send coordination of benefits information, and thus bill secondary
payers electronically.
The honest to goodness truth is, each carrier has different requirements
for what information is required to send secondary claims electronically,
and NONE of the special information they are asking for is stored
in Lytec natively in any manner which allows the Validator to pull
it out for you. This means that extra data entry is required to make
up for the fact that you are not sending the EOB along with the claim
when you are sending it electronically. Just HOW MUCH data you will
need to enter in is completely dependant upon WHO you wish to send
the claims to. They generally fall into 2 categories:
Carriers in category 1 want payment and adjustment
(otherwise known as coordination of benefits) information at the claim
level. This means you only need to send information once per claim
about the whole claim (i.e. how much did the primary pay on the whole
claim, how much did they make you write off, and why?).
Those people who are using the easier way, and are sending secondary
claims to a Medicare intermediary like NHIC, can use the SAME form
that they send their primary claims in on. The way the form knows
that these are secondary claims is based on your choosing the insurance
company type of “Medicare Secondary” on the charges and
payments screen under the secondary insurance tab. Then when printing
claims, you choose Billing\Print Insurance Claims and when prompted
with the options and Include\Exclude Ranges, be sure to choose “secondary
claims” as the type of claim you are submitting.
When using this method, the Validator will ask you,
on each claim, the answers to Medicare’s questions that we could
not pull out of Lytec. If you wish to use custom fields to enter this
information in advance, S&A will be more than happy to help you
create a custom form that can accomplish this.
Either having zero knowledge of practice
management software, or perhaps not caring at all, some carriers have
chosen to go the more difficult route, and require the coordination
of benefits information for EACH DETAIL LINE in addition to at a claim
level!!! This means that when submitting claims to carriers such as
Noridian Medicare, and most Medicaid Carriers, you have to include
information such as:
Claim Level COB Information
· Coordination of Benefits (COB) Payer Paid Amount
· Coordination of Benefits (COB) Allowed Amount
· Coordination of Benefits (COB) Obligated to Accept as Payment
in Full (aka OTAF) Amount
· Claim Adjudication Date
Service Line COB Information
· Coordination of Benefits (COB) Primary Payer Obligated to
Accept as Payment in Full Line Item Amount (CN102)
· Coordination of Benefits (COB) Primary Payer Line Item Approved
(aka Allowed) Amount (AMT02)
· Coordination of Benefits (COB) Primary Payer Line Item Paid
Amount (SVD02)
· Coordination of Benefits (COB) Primary Payer Line Item Adjustment
Reason Code (CAS01 and 02)
· Coordination of Benefits (COB) Primary Payer Line Item Adjustment
Amount (CAS03)
These types of carriers will require
a special form, and you can only send your secondary claims using
this special electronic form file. S&A has already created these
forms, which are available for any HIPAA compliant carrier with the
following custom fields for COB information.
| COB Field |
Pulled from Lytec Field |
Electronic Loop |
Electronic Segment |
| Claim
Level Fields |
| Total Claim Payer Paid Amount |
Claim Payments |
2320 |
AMT*D (AMT02) |
| Total Claim Allowed
Amount |
Billing Custom Field 2 |
2320 |
AMT*B6 (AMT02) |
| Total Claim OTAF
Amount |
Not Pulled |
2320 |
CN102 |
| Claim Adjudication Date |
Billing Custom Field 1 |
2330B |
DTP*573 (DTP03) |
| Detail
Level Fields |
| Primary Payer OTAF Line Item
Amount |
Not Pulled |
2400 |
CN102 |
| Primary Payer Line Item Approved
Amount |
Claim Detail - Custom Field 1 |
2400 |
AMT*AAE (AMT02) |
| Primary Payer Line Item Paid
Amount |
Claim Detail - Custom Field 2 |
2430 |
SVD02 |
| Primary Payer Line Item Adjustment
Amount |
Claim Detail - Custom Field 3 |
2430 |
CAS03 |
| Primary Payer Line Item Claim
Adjustment Group Code |
Claim Detail - Custom Field 4 |
2430 |
CAS01 |
| Primary Payer Line Item Adjustment
Reason Code |
Claim Detail - Custom Field 5 |
2430 |
CAS02 |
Note the following assumptions were made in the forms:
1. The Line Item Date of Adjudication is Taken from the Claim Adjudication
Date
2. If Claim Detail - Custom Field 3 is not filled in, we will not
pull any information from custom fields 4 and 5 (no adjustment information)
3. If Claim Detail – Custom Field 4 is not filled in, we assume
the group code “CO”, which stands for “Contractual
Obligation”. Other possible values for this field (which are
usually on the Primary EOB) include:
a. CR: Corrections and Reversals
b. OA: Other Adjustments
c. PI: Payer Initiated Reductions
d. PR: Patient Responsibility
4. If Claim Detail – Custom Field 5 is not filled in (but 3
is) we will assume “42”. (This is equivalent to a CO-42
on an EOB)
5. All Date custom Fields must be set as a Date field in Lytec
6. All Amount fields must be entered with the smallest number of characters
necessary. For Example, $50.00 would be just 50, $50.50 would be 50.5
and $50.23 would be 50.23.
If these custom fields are not available
in your practice(s), S&A will be happy to make a custom form for
your specific needs. It is also important to note that while these
are the fields that have worked for other clients, each carrier is
different, and there may be some testing necessary to get all of the
fields that the carrier wants.
