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Back  RFI # 206: SECONDARY CLAIM ISSUE

Formal vs. Informal Help Informal Formal

Submitter

Barry Holahan

Description

IF SUBMITTING 2NDARY CLAIM AND PAYMENT/ADJ FROM ADJUD BY PRIMARY PAYER ARE REPORTED AT CLAIM LEVEL IN 2320 LOOP, THEN IS IT ACCEPTABLE TO REPORT REJECTIONS AT THE LINE LEVEL IN LOOP 2430.

Our understanding of the question was: On secondary claims, is it OK to report partial reductions and payment by the primary at the claim level but report service total rejections at the service level? For instance, report deductible and co-insurance CAS adjustments at the claim level with the total claim payment, report a rejected service with a CAS at that specific service and not report service specific payment information at the service level.

Response

The secondary claim must contain prior payer payment, adjustment and rejection code information at the claim level if the prior payer adjudicated and reported the information at that level. If the prior payer adjudicated at the line level, then payment, adjustment and rejection code information must be placed at the line level in the secondary claim. Payment, adjustment and rejection information must not be reported at the line level if that information was adjudicated and reported at the claim level by the prior payer." "If the primary payer's adjudication resulted in both claim level and line level adjudication information, the secondary claim must reflect the information at both levels.

Recommendation

Submission 2/18/2005
Status Date 5/9/2005
Status F - Final
Primary References
Document 004010X098A1
Section3
Page?
Set ID837P