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Back  RFI # 2084: COB Model Service Line

Formal vs. Informal Help Informal Formal

Submitter

Betty Westbrook

Description

Payer is using “COB Model” described in RFI 1670 for a health reimbursement account (HRA). In the example below, the “Healthcare Payment – Primary” 835 they produced looks correct for the one-line professional claim. The 835 for the “Spending Account Payment – Secondary” also looks correct at the claim level, but it also includes service line level information indicating the line was paid in full when it actually was not.

“Healthcare Payment – Primary” 835 includes:
CLP*XXX*1*106*1.86*92.91*HM*XXX*11*1~
MOA***N367~
and
SVC*HC>99213*106*1.86**1~
CAS*CO*45*13.09**137*-1.86~
CAS*PR*1*92.91~

“Spending Account Payment – Secondary” 835 incorrectly indicates the line level was paid in full:
CLP*XXX*2*106*92.91**ZZ*XXXX*11*1~
CAS*OA*23*13.09~
MOA***N520~
and
SVC*HC>99213*106*106**1~

RFI 1670 only address claim level information for the Spending Account Payment - Secondary 835s. What is the appropriate way for the Spending Account Payment - Secondary 835 to be displayed when there are service line payments?

Submitter Assigned Keywords

COB Model, 835, Secondary

Response

Many concepts within the guide and RFIs are presented with examples of their usage at the claim level for simplicity of description. Restating the same information as applying at the service level is duplicative and usually avoided. However, that doesn’t mean that the specific concept is claim specific and not reported at the service level. Service usage with the same concepts is required when the service level itself is required.

The usage of the service level is documented in:

1.10.2.1.1 - "Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim. When used, the submitted service charge plus or minus the sum of all monetary adjustments must equal the amount paid for this service line." While there is a separate part of the section that states a specific algorithm for service balancing, this second sentence is not an algorithm, but is a business statement. For each service, the submitted charge plus or minus the adjustments must equal the service paid amount. This requires that the service paid amount on each service must be accurate.

1.10.2.14 - "Much of the information usage in the 835 depends upon the context of a particular service. ... Information in the SVC segment must frequently work with the Claim Adjustment Reason Codes to give the provider a message that will not result in calls to customer service." This supports the need for reporting complete information at the service level when the service level is present.

As a result, when services are reported on a claim, the service needs to be reporting all of the related information in order to facilitate understanding and automation by the provider. Reporting an SVC03 value that represents the total submitted service charge when that amount is not in fact being paid due to reporting of all adjustments at the claim level is not compliant with the guide.

Prior RFI #1028 has limited applicability and is focused upon what CARC codes to use and how to use them. The question was not related to which CAS segment should be used and would apply equally to the 2100 CAS or the 2110 CAS.
Submission 8/20/2015
Status Date 10/9/2015
Status F - Final
Primary References
Document 005010X221
Section2.4