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Formal vs. Informal Help Informal Formal

Submitter

joanne hoagland

Description

VA Hospital institutional secondary claims are being submitted to Horizon with the SBR09 @ Loop 2320 = MA. To us this indicates that there is a primary Medicare payment, but it actually indicates what medicare would have paid. This is causing problems in our adjudication/balancing of the claim. We suggested to VA that they utilize the "VA" code in the SBR09 at the 2320. They indicate that is not what the code was intended for. Can you provide some HIPAA interpretation in this situation??

Response

The 2320 SBR09 describes the benefit program of the previous payer. Even though an actual payment was not made, the VA reduces the patient liability by what Medicare would have paid. The facility uses payment information from the Medicare-equivalent remittance advice 835 in the COB segment of the secondary claim. In these situations, Medicare A is considered to be the previous payer and therefore MA is the proper code. It would be a misuse of the 2320 SBR09 element to use code VA. Also, use of ZZ would be inappropriate because the guide defines ZZ as an "Unknown" type of payer.

Regarding which AMT should be used for the Medicare equivalent payment
amount, see HIR #405 in which the WG identified that the COB Total
Medicare Paid Amount AMT (qualifier N1) is used only in payer to payer COB
claims. In all other scenarios, the previous payer paid amount is reported
in the Payer Prior Payment AMT (qualifier C4).

Recommendation

Note: The Loop 2320 Coordination of Benefits (COB) Total Medicare Paid Amount AMT segment is removed from version 5010 of the claim to avoid confusion in the future.
Submission 8/27/2007
Status Date 10/29/2007
Status F - Final
Primary References
Document 004010x096A1
Section2320
Page204
Set IDSBR09
Loop2320
Segment PositionSBR09
Code ValueVA