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Back  RFI # 1603: TPL Avoidance

Formal vs. Informal Help Informal Formal

Submitter

Erik Newlin

Description

The trading partner is submitting claims with a claim filing indicator (loop 2320 SBR 09) of 17. They are submitting the billed amount (a second time) in the Co-ordination of Benefits – total non-covered amount field (loop 2320 AMT02) with a qualifier of A8 in the AMT01 field.

1. Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.The TR3 says for the 2320 SBR – “Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send”.

Response

The 2320 Other Subscriber Information loop can be used to pass subscriber, payer, and a non-covered amount when the patient is covered by a payer other than the destination payer but that other payer is known to not cover the services on the claim. The Situational Rule in the 2320 SBR segment is satisfied because the other payer is involved with coverage for the patient, although that coverage does not include the services on the claim. The destination payer is not obligated to process the claim based on this other payer and non-covered amount information if it does not have a cost-avoidance policy that permits it to do so. That is, the destination payer may choose to require that the claim be processed and rejected by the prior payer before considering the claim under its benefits for the patient.

The workgroup will consider modifying the language in the 2320 SBR Situational Rule to clarify this usage in a future version of the guide.
Submission 6/5/2012
Status Date 7/27/2012
Status F - Final
Primary References
Document 005010X222
Section2320