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Back  RFI # 1999: 005010X223 AMT*A8 vs CLM*02

Formal vs. Informal Help Informal Formal

Submitter

Lori Bledsoe

Description

NY Dept. of Health has mandated that NY Medicaid require claim data in a format that X12 does not support.

Example:
X12 837 only supports one payer per COB position (one primary payer, one secondary payer, etc). Within the ANSI 005010x223 (Institutional) file, NY Medicaid is mandating that the AMT*A8 must equal CLM*02.

In the most simple example, a patient presents for both medical and dental services on the same day at the practice. NY Medicaid requires that all services be included on one claim.
1. Medical services bill to primary payer = United Healthcare, secondary payer = NY Medicaid.
2. Dental services bill to primary payer = Delta Dental, secondary = NY Medicaid.
There is no valid 837 format that can identify both United and Delta Dental as the primary payer when billing the secondary claim.

Submitter Assigned Keywords

NY Mcaid COB AMT*A8 CLM*02

Response

X12 can only speak to the examples supplied within this RFI. If there are other examples, those should be submitted as RFI as well. If there is a concern regarding compliance with HIPAA, the submitter should file a formal complaint with the National Standards Group (NSG). Complaints can be filed electronically at: https://htct.hhs.gov/aset/.

In regards to the coordination of benefits total non-covered amount (2320 AMT with A8 qualifier). The situation rule reads: “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”.

The TR3 note reads: “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.”

It is compliant to require the AMT02 equal the CLM02 as long as the payer listed in the associated 2330B NM1 was completely bypassed and did not adjudicate any service on the claim. If the payer did adjudicate any service on the claim then it is not compliant to use this segment.

The submitter also inquired about allowing multiple primary payers within a single claim. The note for the 2000B SBR01 and 2320 SBR01 reads: “Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value “U”) may occur no more than once.”

For this reason it is not compliant to define multiple payers as the primary payer for a claim.

For COB transitions the following functionality is not compliant with the TR3 guides:

•Merging multiple primary claims into a single secondary claim.
•Including a type of service on the COB claim which could not be included on the primary claim for example placing dental services on an institutional claim form.

For more information on COB transactions see section 1.4.1 of the TR3. This section identifies how to create a COB claim and how the data is to flow between the different responsible payers.
Submission 12/9/2014
Status Date 2/17/2015
Status F - Final
Primary References
Document 005010X223
Section2.4
Table2
Loop2320