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Back  RFI # 1860: 837P Prior Payer Paid Amount

Formal vs. Informal Help Informal Formal

Submitter

Cynthia Fiore

Description

How should the Primary Payer's Paid Amount be reflected in the Secondary Payer's 837 when the prior payer's paid amount were funds paid to the subscriber? Provider Bills the Primary, the primary then paid the claim to the subscriber using a CAS*PR*100.
Provider then Bills the Secondary as follows
(2300)
CLM*C076928482321*11.28***11:B:1*Y*A*Y*Y*P~

(2320)
CAS*PR*100*7.85*10*2*1.96*10*45*1.47*10~
AMT*D*0~
In the situation where a primary payer paid the subscriber should the AMT*D reflect what the prior payer actually paid on the claim?
What is implied by section 1.4.4.1 Claim Level Payment Amount? The TR3 does not indicate to exclude the payment to the subscriber. If it is included the Claim will not balance.

Should the submitter to the secondary payer indicate the PR 100 as a 'paid by primary payer amount' either in the SVD or claim level AMT? Or should the secondary payer convert the CAS*PR*100 into a paid amount. If left as a CAS*PR the secondary payer would consider paying it and overpay.

Response

The presence of this CAS PR indicates paid to patient amount of 7.85 as well as co-insurance of 1.96 and charge exceeds fee schedule maximum allowable of 1.47.

The AMT*D*0 indicates that nothing was paid to the primary provider by the primary payer, but the secondary provider payer must utilize the paid to patient amount in their consideration of remaining benefit to the patient/insured.

The PR 100 would be reported according to how it was processed by the primary payer using the logic from one of the sections referenced below for claim level or service line level.

In 1.4.1.1.1 Coordination of Benefits -- Claim Level there is directions to report all claim related adjustments.

In 1.4.1.1.2 Coordination of Benefits -- Service Line Level there is directions to report all service related adjustments.

1.4.4.1 Claim Level Payment Amount is a representation of any payment that applies to the claim as a whole and is not related to any specific line item. I.e. Deductible or Co-insurance.
Submission 9/25/2013
Status Date 10/25/2013
Status F - Final
Primary References
Document 005010X222A1
Section1.4.4.1
Page35