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Back  RFI # 1689: 837P Copay Coins Deduct

Formal vs. Informal Help Informal Formal

Submitter

Holly George

Description

We (clearinghouse) are receiving requests from payers of HMO plans to report patient Co-pay, coins & deduct amounts in encounter claims being sent to them by Medical Groups. This is related to changes being made by the 'Affordable Care Act' & the Max Out of Pocket (MOOP) expenses for Medicare Advantage plans. Information can be found in 75 FR 19678.

Payers indicate that the 2300 loop AMT*F5 is not sufficient enough & are asking for the Co-pay, coins & deduct amounts in the CAS segments of the 2320 \ 2430 loops. The problem is providers are sending encounter claims as a primary & the 2320 \ 2430 CAS segments can only be sent when billing a second payer.

We are seeking direction from X12 for this situation. Will there be development in the next 837P release to include reporting of the co-pay, coins and deduct amounts in the 2300 loop so the encounter claim will not have to be billed as a second?

Please provide some direction on how this data should be reported currently on an encounter claim.

Submitter Assigned Keywords

Reporting patient out-of-pocket expenses

Response

The 5010 837 Professional TR3 does not support the reporting of co-pay, co-insurance, or deductible amounts in the 2300 loop.

If there is a business need to report these values as described in the RFI, please submit a Designated StandardMaintenance Organizations (DSMO) request to http://www.hipaa-dsmo.org/. It would be helpful if this included a more specific reference within 75FR 19678 that summarizes the applicable provisions in the rule.
Submission 9/28/2012
Status Date 12/3/2012
Status F - Final
Primary References
Document 005010X222
Section2300
Page188
Loop2320
Segment PositionCAS