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Back  RFI # 2025: 835/837Payer Crossover Process

Formal vs. Informal Help Informal Formal

Submitter

Betty Westbrook

Description

Rural Health Clinic (RHC) Services provided to beneficiaries covered by Medicaid Managed Care Organizations (MCO) where Medicaid is responsible for payment of RHC services. Provider submits claim to MCO. MCO sends notice of non-payment via 835 to provider using Claim Status (CLP02) equal to 1. MCO crosses 837 data to Medicaid. Medicaid pays claim via 835 using Claim Status (CLP02) equal to 1. MCO will report patient responsibility in a separate transaction to Medicaid, Medicaid will issue adjusted 835’s to providers quarterly so that providers can bill the patient.

Seeking guidance from X12

1. Correct usage of 835 Claim Status in CLP02 for the MCO and Medicaid.
2. MCO CARC/RARC Assignment: For this scenario would the correct CARC/RARC combination be
a. CARC 96
b. RARC N193
3. Is it permissible for the MCO to modify the original 387 data received from providers in order to insert the amount they’ve deemed to be patient responsibility in the 2320 CAS segments OR 2430 Line Adjudication Information?

Response

According to your description, the MCO is providing a crossover claim to Medicaid. As a result, the 835 from the MCO to the provider
must report CLP02 code "19" (meaning "Processed as Primary, Forwarded to Additional Payer(s)"). Use of code "1" is not compliant with the TR3 since that
isn't the correct representation of the actions taken. When Medicaid sends an 835 to the provider, the CLP02 value of "1" (meaning "Processed
as Primary") is appropriate since the MCO did not cover the claim at all and Medicaid is paying as if the MCO had not been involved.

2 - Identifying the proper CARC/RARC combination for this scenario is not about the TR3, and can't be determined by this response. See the
recommendation below.

3 - Guide 005010X222A1 section 1.4.1.1, Model 2, step 2 states "All COB information from Payer A is placed in the appropriate Loop ID-2320
and/or Loop ID-2430." The guide doesn't further define "COB information". That section also defines reformatting the claim and does not include
changing any of the original data from the provider. As a result, the MCO can't "modify the original 837 data received from providers", but can
insert their determination of patient responsibility information in the appropriate Loop ID-2320 and/or Loop ID-2430 in the crossover COB
claim as determined by their relationship with Medicaid.

Recommendation

For question 2 - The selection of a CARC/RARC would also depend upon business specifics not present in this request, including but not limited
to:
- Is the business that RHC services are not part of the patient's benefit package with the MCO? Consider CARC 204.
- Is the business that the MCO is not the correct payer/contractor for processing the claim? Consider CARC 109.

Since the business stated includes an expectation that this is covered by Medicaid, usage of CARC 96 with RARC N193 seems inappropriate as it looks like more specific CARC codes can be applied.
Submission 3/7/2015
Status Date 6/11/2015
Status F - Final
Primary References
Document 005010X221
Section2