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Back  RFI # 291: file 2nd clm when capitated pr

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Submitter

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Description

Filing secondary claims when primary is a capitated policy (only Co-pay remains).
Is there any documented information about how or if providers can bill Secondary claims electronically when the primary is a capitated policy/payer? In that instance only the co-pay remains.
Or does that fall under the unusual circumstances and paper billing is allowed?

Submitter Assigned Keywords

primary capitated policy/payer

Response

A secondary claim can be submitted electronically when the primary coverage was managed care/capitation and only a co-payment remains. The primary, managed care payer would be listed in the 2330B Other Payer loop. Adjustment amounts would be shown for the capitation and co-pay amounts in the adjustment CAS segment corresponding to that primary payer. The Claim Adjustment Reason Code for the capitation reduction is "24", and the code for the co-pay is "3".

For example, if the charge is $100, and a $20 co-pay remains, the CAS would contain a code 24 adjustment for $80, and a code 3 adjustment for $20. The secondary payer should interpret this correctly and consider the patient's liability of $20 for payment."
Submission 8/2/2005
Status Date 11/1/2005
Status F - Final
Primary References
Document 004010X098A1
Section3
Page?
Set ID837P