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Back  RFI # 2187: One payer MedicareMedicaid 835

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

2100 REF*CE is Medicare/Medicaid (MMP Duals) – ONE payer ONE Member ID with payer – not a COB situation. Patient has a Medicare ID and Medicaid ID they were issue by state. The claim has Medicare benefits applied then Medicaid benefits. Some states require that the remit shows the adjustments by Medicaid and Medicare separate but does not dictate to processed under sep claims. The CLP06 and CLP02 does not account for this dual contract condition to report all in ONE CLP. The line technically is adjudicated twice with two respective allowances and payments. How should this be handled?
• Show two CLP02’s equal to 19 and 2 respectively (with MB/MA in one and MC in second)?
• For CLP07 would that need to be different?
• For the Medicaid claim the MC amounts not covered due to Medicare adjudication would be reported as OA 23?
• Is there a way to show this all in one CLP?
I do have some examples that I can share. Please contact the requestor.

Submitter Assigned Keywords

CLP02 CLP06 CLP07 Medicare Medicaid

Response

The 005010X221A1 TR3 does not support sending adjustments for multiple payments from different payer products (i.e., Medicare and Medicaid/duals within the same payer) of the member's plan in a single CLP segment. Adjustments need to be reported for each payer product in a separate CLP within a single 835 transaction. The CLP02 element values of '19' for the claim processed under the Medicare benefit product and then '2' for the claim processed under the Medicaid benefit product appear appropriate for the scenario you describe. The 835 does not provide guidance on the value in CLP07.
Submission 12/16/2016
Status Date 4/25/2017
Status F - Final
Primary References
Document 005010X221
SectionDetail