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Back  RFI # 2023: COB claim vs service line

Formal vs. Informal Help Informal Formal

Submitter

Janett Checo

Description

Does the 5010 TR3 specify at which level a submitter must submit coordination of benefit information? In reading the TR3, it appears to be dependent on the prior payer's adjudication. However,some receivers (secondary payers) appear to require providers to submit COB as claim level if inpatient 837I and service line for Outpatient 837I and all 837P. If a prior payer adjudication exists at claim level for an outpatient claim (837I), how is a provider to report the data at service line? Does the TR3 provide any direction that perhaps has been missed?

Your feedback is greatly appreciated. It is not clear if there is receiver discretion to require data that may not exist at a particular level and if so, how that is accomplished.

Submitter Assigned Keywords

COB CAS submitter discretion prior payer adjudication 5010 TR3 coordination

Response

The health care claim payment TR3 allows a payer to return adjustment information in either the header (835 2100 CAS segment) or in the detail (835 2110 CAS segment).
If the adjustment information is communicated by the payer using the 835 2100 CAS segment then the adjustment is reported in the 837 2320 CAS on subsequent COB claim transactions.

If the adjustment information is communicated by the payer using the 835 2110 CAS segment then the adjustment is reported in the 837 2430 CAS on subsequent COB claim transactions.

If the provider cannot assign an adjustment to a line, which might be the case with a paper EOB, then the adjustment is reported in the 837 2320 CAS on subsequent COB claim transactions

The TR3 does not allow for the data receiver to establish rules which would require information received in the 835 2100 CAS to be reported in the 837 2430 CAS or for information received in the 835 2110 CAS to be reported in the 837 2320 CAS.
Submission 3/3/2015
Status Date 4/6/2015
Status F - Final
Primary References
Document 005010X223