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Back  RFI # 2288: Billing Provider for MedSub

Formal vs. Informal Help Informal Formal

Submitter

Kimberly Kennedy

Description

Hi,

I work for a clearinghouse and we are submitting Medicaid Subrogation claims (TPL) on behalf of a Medicaid State Agency for MCOs. I am confused on whether we should be submitting the Medicaid State Agency or the Treating Facility in Loop 2000A Billing Provider in the 837I, 837P and 837D. We are recouping the money for Medicaid. Can you please explain this Loop for Medicaid Subrogation purposes?

Thank you!

Submitter Assigned Keywords

Billing Provider, TPL, Medicaid Subrogation

Response

Medicaid Subrogation is explicitly supported in all three version 5010 837 TR3’s.

Section 1.4.1.5 Coordination of Benefits - Medicaid Subrogation reads in part:

“These pay-to-plan claims are identified by the inclusion of Loop ID-2010AC Pay-to Plan Name Loop. Medicaid subrogation claims include the Medicaid agency’s own payer claim control number in Loop ID-2300 data element CLM01 rather than the provider’s patient control number. The Medicaid paid amount, indicated in Loop ID-2320 data element AMT01, represents the maximum amount of liability the Medicaid agency is requesting to recover by submitting the claim.

The Medicaid agency is identified in Loop ID-2330B (Other Payer Name). Loop ID-2320 and Loop ID-2430 include all required segments to indicate the Medicaid agency’s adjudication of the original claim submitted to that agency. Receiving payers are to direct information requests about the claim to the Medicaid agency rather than to the original service provider.”

The Loop 2300 NM1 - PAY-TO PLAN NAME is “Required when willing trading partners agree to use this implementation for their subrogation payment requests.”

When the Pay-to-Plan loop is used, the Billing Provider 2010AA loop must contain the billing provider information which was submitted in the original claim.
Submission 5/9/2018
Status Date 6/15/2018
Status F - Final
Primary References
Document 005010X223
Section2.4
Loop2000A