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Back  RFI # 626: 835 COB Secondary Payer

Formal vs. Informal Help Informal Formal

Submitter

Cynthia Anaya

Description

I understand that there are multiple ways to respond on an 835 for COB claims from secondary payers. It is not clear to us in the 835 IG (004010X91/004010X91A1) and there is nothing in the front matter for clairificaiton on COB. Please advise.

Submitter Assigned Keywords

COB Secondary Payer 835

Response

Handling of secondary payments is not explicitly addressed in the 004010X091 guide. See the recommendation for suggested handling.

Recommendation

From the perspective of the secondary payer, the impact of the primary payer’s adjudication is a reduction in the payment amount. This impact may be up to the actual amount of the primary payment(s) plus contractual adjustment(s). Report the impact in the appropriate claim or service level CAS segment with reason code 23 and Claim Adjustment Group Code OA. Code OA is used to identify this as an administrative adjustment. If a secondary payer allows more than the submitted amount, the claim MUST still balance. This is reported as a CAS segment with a group code OA and a reason code 94 with a negative dollar amount. From that point, apply all normal CAS adjustments to derive the net reimbursement amount. It is essential that any secondary payer report in the remittance advice only the primary amount that has actually impacted their secondary payment. In many cases, this impact is less than the actual primary payment. When this happens, reporting the actual payment would prevent the transaction from balancing.
Submission 2/6/2008
Status Date 5/5/2008
Status F - Final
Primary References
Document 004010X091
SectionCAS
Page95
Set ID835
Table2
Loop2100