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Back  RFI # 1743: Member Cost Share Submission

Formal vs. Informal Help Informal Formal

Submitter

Laurie Dean

Description

Need to identify member cost share (MCS) by copayment, coinsurance, deduct. in 837 Encounter nonpayable reportable only in CAS.
837 as COB encounter is not true COB
No indicator in the 837 to advise if true COB encounter
837 Balancing required
Balancing edits
Balancing edits encounters reject
CAS used to adjust bal. remaining so the encounter will balance
New post adjudicated claim TR3 doesnot solve the issue
No standard for submission of MCS to health plans
Done at Clearinghouse as providers donot want to submit encounters in different formats
adjusted for balancing this is not the true claim adjud.
Audits at plan and provider
Plans are required to send CMS an 837 for Risk Adj. as of 01012012
Provs. have requested for Plans to receive a nonstandard format.
What do you recommend for the cap. groups to submit MCS in 837s once claim is adjudicated?

If the cap. groups submit the MCS in CAS this creates a COB but isn't COB. This is payer2payer.

Do we have a P2P 837 for non-payable encounters?

Submitter Assigned Keywords

Membe Cost Share Submission

Response

A representative from the organization who submitted this RFI further clarified the interpretation request with this question. "Is there a TR3 compliant way to report post-adjudicated encounters that include discrete member responsibility amounts, but not the paid amount."

The PACDR (005010x298, 005010x299, 005010x300) guides support this business need.
Submission 1/31/2013
Status Date 6/10/2013
Status F - Final
Primary References
Document 005010X291
SectionCAS