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Back  RFI # 1919: Medicare Subrogation

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Submitter

Claudette Sikora

Description

CMS is seeking guidance from the ASC X12 to use the 5010A1 version of the ASC X12 837 professional TR3 to process Medicare subrogation claims.

In accordance with 42 U.S.C. § 1395u(b)(6)(B); and 42 C.F.R. 424.66, Medicare is required to pay Part B claims under an Indirect Payment Procedure (IPP) to qualifying entities under qualifying conditions. In this IPP, the entity seeking payment has provided a complementary health benefit plan to a Medicare beneficiary and has paid a Medicare provider for the services the beneficiary has received. Medicare is required to reimburse the IPP (when certain qualifications are met). Currently Medicare is processing these claims via paper. While the current volume of paper IPP claims is manageable, we anticipate more complementary health plans to become registered to submit IPP claims, and the volume of IPP claims to increase significantly over time. Therefore, CMS would like to establish a process for submitting these claims electronically as soon as possible.

Submitter Assigned Keywords

Medicare subrogation Indirect Payment Procedure

Response

The 5010 837 Professional, Institutional, and Dental TR3’s do not support Subrogation Demands involving Medicare due to the specific restrictions in the TR3’s for this use by Medicaid agencies only.

If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at http://changerequest.x12.org/

Note: DSMO change request 1192 has subsequently been received by ASC X12N and is being processed in accordance with ASC X12N procedures.
Submission 4/9/2014
Status Date 6/13/2014
Status F - Final
Primary References
Document ASC X12 837
Section2.4
Page106
Set ID837
Table2
Loop2010AC
Segment Position0150
Segment IDNM1
Element Position01
Component Position98
External Code List540 (HPID/OEID)
Code ValuePE
Secondary References
RFI ID 2392
Document 005010X222
Section2.4
Page72
Set ID837
Table1
LoopBHT
Segment Position0100
Segment IDBHT
Element Position06
Industry NameClaim or Encounter Identifier
Code Value31