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Back  RFI # 2229: Tertiary claim with no primary

Formal vs. Informal Help Informal Formal

Submitter

Melissa Rivera

Description

We have a claim for a tertiary payer (Loop 2000B, SBR01 = T), but on Loop 2320, there is no information about a primary payer, only secondary. Our validator rejected the claim due to the missing information for the primary payer. On a previous response (RFI 1151), it was stated that is was not required to send the payers that are not involved in paying the claim, Would that apply even if it is the primary payer? Should there always be an instance of primary payer on Loop 2320 when the claim is sent to a tertiary or other subsequent payer?

Submitter Assigned Keywords

SBR tertiary COB

Response

No, a payer is only required to be included on a claim if the payer is involved in payment. If the primary payer was not involved in payment then it can be omitted.

Recommendation

If a payer is not involved in payment on a claim, that payer information may be submitted on subsequent claims. When submitting this prior payer information, Loop 2320 includes the Coordination of Benefits I(COB) Total Non-Covered Amount (Loop 2320 AMT01=A8). When this segment is used, the amount reported in the AMT02 must equal the total claim charge amount.
Submission 8/23/2017
Status Date 2/2/2018
Status F - Final
Primary References
Document 005010X224
Section1.4.1
Page221
Set ID837
Loop2320