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Back  RFI # 1535: 837D COB & Hlth Plan req 2430

Formal vs. Informal Help Informal Formal

Submitter

Cindy Monarch

Description

Our understanding of the 837D TR3 requirements is that a provider can report COB payment information at claim level (2320) or at service line level (2430). The reporting of COB payment information is based on how the other payer reported payment via the 835 (claim level or service line level). We have a health plan requiring COB payment information always be reported at service line level (2430). We believe this to be non-compliant with the 2430 SVD situational rule. Is our understanding correct and is requiring COB payment information to always be reported at service line level (2430) considered non-compliant?

Submitter Assigned Keywords

837D COB always include 2430

Response

Guide 005010X224 section 1.4.1.1, Model 1, Step 2 states "Any claim level adjustment codes are retrieved from the 835 from Payer A and put in the CAS (Claims Adjustment) segment in Loop ID-2320. Line Level Adjustment reason codes are retrieved similarly from the 835 and go in the CAS segment in the 2430 loop." The situational rule on the 2430 loop reads "Required when the claim has been previously adjudicated by the payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send."

Guide 005010X221 (835) section 1.10.2.1.1 states "Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim." Since the word "professional" is not capitalized, this does not refer to "Professional Claims" as in related to the 837P, but to claims rendered by persons rather than institutions, making that statement applicable to Dental claims.

Situation 1 - The provider receives an 835 from the prior payer - Having received an 835 from the prior payer, the 835 2110 loop (Service Detail) is present and the provider is obligated to report the information from each 2110 loop within the 837D 2430 loop. The provider must also report any claim level adjustments received in the 835 2100 loop within the 837D 2320 loop. Please note - this may result in a service reporting as paid in full at the 2430 loop with claim level adjustments in the 2320 loop removing that payment.

Situation 2 - The provider receives a paper remittance - The provider must report the information from the paper remittance advice as received within the 837D 2320 and 2430 loops. If the paper remittance advice included service detail, then the 837D must include 2430 loops to convey that detail. If the remittance did not include service detail, then the 2430 loops must NOT be conveyed in the 837D for that other payer.

Since the provider is obligated to not include service detail if the paper remittance did not include service detail, it is not consistent with guide 005010X224 for a health plan that is the current payer to require the presence of the service (2430) loop for prior payers on non-primary claims. In addition, since there is no way within the 837D for the current payer to identify when the provider received a paper remittance that only included claim level information, this situation is not able to be validated by the receiving payer.
Submission 3/5/2012
Status Date 5/25/2012
Status F - Final
Primary References
Document 005010X224
Section2.4
Page341
Table2
Loop2430
Segment IDSVD