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Back  RFI # 2199: Additional Info - RFI #2189

Formal vs. Informal Help Informal Formal


Tia Martinez


Please Reference 2189 response. Although it is appropriate to include other subscriber information on a primary claim. In this situation we are "Payer of last resort". The provider submitted the claim to another Medicaid agency, received a denial/reject for the member not having coverage under that health plan, and sent the claims to us (who actually covers the member), showing us as Primary and the other health plan(s) as Secondary and/or Tertiary. We feel this is reporting of incorrect data (even though it is syntactically sound) since the other health plans do not actually cover the member and were billed incorrectly before us. Would the other health plans truly be considered "potential payers" even though they were just billed incorrectly?


This response expands on RFI 2189.

When the claim is submitted to a payer that is then determined to not have a financial interest in the claim, the information regarding the incorrect submission does not need to be included in subsequent submissions to other payers. If the information regarding the incorrect submission is included on the claim, then the submitter must include all appropriate COB information on the claim.

In the example supplied the payer is receiving incorrect data within the subsequent payer loop, namely that the payer which received the claim in error is a subsequent payer to the destination payer. X12 cannot comment on individual payer processing rules or procedures for addressing incorrect data within the transaction. Although submission of incorrect data may result in further payment delays, it is compliant with the TR3.


If necessary to include information on an incorrect claim submission, the payer should be shown as a previous payer instead of a potential future payer.
Submission 2/21/2017
Status Date 7/13/2017
Status F - Final
Primary References
Document 005010X222A1
Segment PositionSBR
Element Position01