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Back  RFI # 1233: MSP SVD3-03 requirements

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Submitter

Will Holley

Description

We need clarification regarding if a payer can require specific modifiers in the SVD3-03 segment when submitting COB2 claims. Railroad Medicare currently is requiring that the modifiers match in the SV1 and SVD segments when submitting a MSP claim.

We have an situation where the primary payer BCBS requires a specific modifier P2, BCBS processes and adjudicates back via ERA. When we create our RR Cob2 claim the 2430 SVD segment includes what was adjudicated by BCBS, including modifier P2. Railroad Medicare is denying the claim due to P2 being present in segment SVD and not their required modifier QZ. While the modifier QZ is reported in SV101-3 as required, Medicare is also requiring that the SV1 and SVD must match. Our understanding is SVD has to populate based on how the primary processed/adjudicated the claim.
Thank you,
Will Holley

Response

The loop 2430 SVD segment reports the adjudication information of the payer identified in loop 2330B. The element note on SVD03 in guide 004010X098A1 states "This element contains the procedure code that was used to pay this service line. It crosswalks from SVC01 in the 835 transmission." The SVD03 represents the medical procedure code and modifiers upon which adjudication of this service line was based. Therefore, the SVD03 must contain the procedure code and modifiers that the payer identified in loop 2330B used as the basis for their adjudication of the service line.
Submission 1/26/2011
Status Date 3/11/2011
Status F - Final
Primary References
Document 004010X098A1
Section3.1Trans
Page533
Set IDNotSur