Billing of Claims to Medicare when Expected to Cross Over to the ihcp




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Billing of Claims to Medicare when Expected to Cross Over to the IHCP
Claims Submitted to Medicare for Services That Electronically Cross Over to the IHCP Using the 837COB (Provider-to-Payer-to-Payer) Model 2
Crossover claims from Medicare (837COB) are currently received without proper information being transmitted in the COB loops. For crossover claims to pass pre-adjudication and pay, providers must provide information needed by the IHCP for adjudication when submitting 837 transactions to Medicare. The following information must be submitted in 837COB transactions.
After Medicare adjudicates the claim, the transaction is reformatted by moving the COB loops with the IHCP required information to the destination payer loops and transmitting the 837COB data to the IHCP. The following information from the 837 implementation guide front matter is used for this.
Payer-to-Payer COB
With the exception of Medicare crossover claims, most payers only accept COB claims from providers.
This section has been added to the 837 health care claims professional implementation guide if a trading partner wishes to automate the COB process. Trading partners interested in automating the COB process include payers and providers or their representatives. The purpose of the information below is to clarify the exact data that must be moved within the 837 transactions to facilitate a COB automation. Either payers or providers can elect to use this method.
For the purposes of this information, there are two types of payers in the 837 as follows:

  1. The destination payer (payer receiving the claims) who is defined in the 2010BB loop (for example, Medicare)

  2. The other payers, or payers defined in the 2330B loop(s) who receive the reformatted claim from the primary payer (for example, EDS).

The destination payer or other payer may be the primary, secondary, or any other position payer in terms of when they are paying on the claim. The payment position is not important for managing the 837 in a COB situation. However, for information contained in this document, it is only relevant to differentiate between the destination payer and any other payer contained in the claim.


In a COB situation, each payer indicated on the claim has an opportunity to be the destination payer. As the destination payer changes, the information identified with that particular payer must stay associated with that payer. The same is true of all the other payers, who will each, in turn, become the destination payer as the claim is forwarded to them for adjudication. The example below demonstrates how payer-specific information stays associated with the correct payer as the destination payer rotates through the various COB payers.
Tables 1 and 2 illustrate data specific to a payer including where data is contained for the destination payer and where it is contained for any other payers included on the claim.
Example
A provider submits a claim to Medicare that will electronically cross over to the IHCP for adjudication. The information needed by Medicare for adjudication would be submitted in the 2300, 2310, 2400, and 2420 loops of the 837 transactions. The information required by the IHCP is carried in the 2320 and 2330 loops of the 837 COB transaction.
Tables 1 and 2 list information specific to the destination payer (Medicare) contained in the elements in the second column (Medicare Information). Information specific to the non-destination payers (EDS) is contained in the elements listed in the third column (IHCP Information). After Medicare adjudicates the claim, it is re-formatted and crossed over electronically to the IHCP for adjudication as a crossover claim. The outcome of the IHCP crossover claim (paid or denied), when the provider has not submitted the claim as instructed in column 3 is described in the last column.

Table 1 – 837P Crossover Claim Information

Data Element Name

Medicare Information

IHCP Information

IHCP Crossover Adjudication Outcome When the 837P Transaction is not Submitted as Instructed in Column 3

Billing Provider Secondary ID

2010AA | REF Segment repeats 8 times. Once with

REF01 = 1C

REF02 = Medicare Billing provider number


2010AA | REF

Segment repeats 8 times. Once with REF01 = 1D

REF02 = Medicaid Billing provider number


Rejected in the pre-adjudication editing (BSR).

Subscriber Last Name

2010BA | NM103

2330A | NM103

Denied when required by the IHCP provider manual billing instructions.

Subscriber First Name

2010BA | NM104

2330A | NM104

Denied when required by the IHCP provider manual billing instructions.

Subscriber Identification Number

2010BA | NM108/09

NM109 = Medicare Member ID



2330A | NM108/09

NM109 = Medicaid Member ID



Denied when required by the IHCP provider manual billing instructions.

Pregnancy Indicator

2010B | PAT09

(if patient pregnant)



2000B | PAT09

Denied when required by the IHCP provider manual billing instructions.

Payer Name

2010BB | NM103

2330B | NM103

Please refer to the IHCP companion guide for appropriate billing instructions.

Payer ID

2010BB | NM108/09

2330B | NM108/09

Please refer to the IHCP Companion Guide for appropriate billing instructions.

Claim Supplemental Information

2300 | PWK

2300 | PWK belongs to the primary payer

This data element will be ignored by the IHCP.

Referral Number – claim level

2300 | REF01/02

2330C | REF01/02 Referral Number REF

Denied when required by the IHCP provider manual billing instructions.

Claim Note

2300 | NTE02

2300 | NTE02 belongs to the primary payer

This data element will be ignored by the IHCP

Referring Provider Secondary ID

2310A | REF01/02

REF01 = 1C



2330D | REF01/02 REF01 = 1D

Denied when required by the IHCP provider manual billing instructions.

Rendering Provider Secondary ID

2310B | REF01/02

REF01 = 1C



2330E | REF01/02 REF01 = 1D

Denied when required by the IHCP provider manual billing instructions.

Coordination of Benefits (COB) Payer Paid Amount (TPL) for payers other than Medicare and Medicaid

All AMTs in the 2320 loop are specific to the payer identified in the 2330B loop of that iteration of the 2320 loop.

All AMTs in the 2320 will be crossed over as received for the payer identified in the 2330B loop of that iteration of the 2320 loop.

Denied when required by the IHCP provider manual billing instructions.

Line Counter

2400 | LX01

2400 | LX01

The IHCP will process the first 33 details only of the 837P transaction. Claims submitted with more than 33 details will need to be submitted as a separate crossover claim by the provider.

Procedure code

2400 | SV101-2

2400 | SV101-2

Currently claims that are submitted to Medicare may be billed with a CPT/HCPCS procedure code that is different than the CPT/HCPCS procedure code that is required for submission to the IHCP. These denied claims may be resubmitted to the IHCP, with the IHCP required CPT/HCPCS electronically or by paper.

HCPCS Modifiers

2400 | SV101-3 thru SV101-6

2400 | SV101-3 thru SV101-6

Currently claims that are submitted to Medicare may or may not require a modifier that is required for submission to the IHCP. These denied claims may be resubmitted to the IHCP, with the IHCP required modifiers electronically or by paper.

Procedure code

2400 | SV101-2

2400 | SV101-2

Currently claims that are submitted to Medicare may be billed with a CPT/HCPCS procedure code that is different than the CPT/HCPCS procedure code that is required for submission to the IHCP. These denied claims may be resubmitted to the IHCP, with the IHCP required CPT/HCPCS electronically or by paper.

Service Line Paid Amount (TPL) for payers other than Medicare and Medicaid specified in the SVD01

2430 | SVD02

Service Line Paid Amount for the payer specified in SVD01



2430 | SVD02

All AMTs in the SVD02 will be crossed over as received for the payer identified in the SVD01.



Service Line TPL will be calculated in the Header level TPL.



Table 2 – 837I Crossover Information

Data Element Name

Medicare Information

IHCP Information

IHCP Crossover Adjudication Outcome When the 837I Transaction is not Submitted as Instructed in Column 3

Billing Provider Secondary ID

20100AA | REF Segment repeats 8 times. Once with REF01 = 1C

REF02 = Medicare Billing provider number



2010AA | REF Segment repeats 8 times. Once with REF01 = 1D

REF02 = Medicaid Billing Provider Number



Rejected in the pre-adjudication editing (BSR)

Subscriber Last Name

2010BA | NM103

2330A | NM103

Denied when required by the IHCP provider manual billing instructions.

Subscriber First Name

2010BA | NM104

2330A | NM104

Denied when required by the IHCP provider manual billing instructions.

Subscriber Identification Number

2010BA | NM108/09

NM109 = Medicare Member ID



2330A | NM108/09 NM109 = Medicaid Member ID

Denied when required by the IHCP provider manual billing instructions.

Payer Name

2010BB | NM103

2330B | NM103

Please refer to the IHCP companion guide for appropriate billing instructions.

Payer ID

2010BB | NM108/09

2330B | NM108/09

Please refer to the IHCP companion guide for appropriate billing instructions.

Claim Supplemental Information

2300 | PWK

2300 | PWK

This data element will be ignored by the IHCP.

Referral Number – claim level

2300 | REF01/02

2330C | REF01/02 Referral Number REF

Denied when required by the IHCP provider manual billing instructions.

Claim Note

2300 | NTE02

2300 | NTE02

This data element will be ignored by the IHCP.

Attending Physician Secondary ID

2310A | REF01/02

2330D | REF01/02

REF01 = 1D

REF02 = State License Number


Denied when required by the IHCP provider manual billing instructions.

Operating Physician Secondary ID

2310B | REF01/02

2330E | REF01/02

REF01 = 1D

REF02 = State License Number


Denied when required by the IHCP provider manual billing instructions.

Other Provider Secondary ID

2310C | REF01/02

2330F | REF01/02 REF01 = 1D

REF02 = State License Number



Denied when required by the IHCP provider manual billing instructions.

Coordination of Benefits (COB) Payer Paid Amount (TPL) for payers other than Medicare and Medicaid

All AMTs in the 2320 loop are specific to the payer identified in the 2330B loop of that iteration of the 2320 loop.

All AMTs in the 2320 will be crossed over as received for the payer identified in the 2330B loop of that iteration of the 2320 loop.

Denied when required by the IHCP provider manual billing instructions.

Line Counter

2400 | LX01

2400 | LX01

The IHCP will process the first 49 details only of the 837I transaction. Claims submitted with more than 49 details will need to be submitted as a separate crossover claim by the provider.

Procedure code

2400 | SV101-2

2400 | SV101-2

Currently claims that are submitted to Medicare may be billed with a CPT/HCPCS procedure code that is different than the CPT/HCPCS procedure code that is required for submission to the IHCP. These denied claims may be resubmitted to the IHCP, with the IHCP required CPT/HCPCS electronically or by paper.

HCPCS Modifiers

2400 | SV101-3 thru SV101-6

2400 | SV101-3 thru SV101-6

Currently claims that are submitted to Medicare may or may not require a modifier that is required for submission to the IHCP. These denied claims may be resubmitted to the IHCP, with the IHCP required modifiers electronically or by paper.

Service Line Paid Amount (TPL) for payers other than Medicare and Medicaid specified in the SVD01

2430 | SVD02

Service Line Paid Amount for the payer specified in SVD01



2430 | SVD02

All AMTs in the SVD02 will be crossed over as received for the payer identified in the SVD01.



Service Line TPL will be calculated in the Header level TPL.


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