Jonathan
I'm not 100% sure I understand your question but let me take a shot at it. I'm
looking at this from the payer perspective ('in' = into the payer, 'out' =
generated by the payer and sent out)
I think it's actually a non-issue. The rule is, if a payer receives a claim which
has 10 lines, they adjudicate the claim and must return at least 10 lines in the
835. If one line is not a covered benefit, then the payment on that line is
adjusted to $0.00. BUT, the rule of thumb is 10 lines in = 10 lines out. So, in
a COB 837, for EVERY payer (regardless of whether the line represents a covered
benefit or not), the payer gets 10 lines in, they produce an 835 with 10 lines.
This includes even when a payer bundles (see the excellent discussion on bundling
in the 835 Intro). If a payer bundles a line they still must include that bundled
line (with zero payment) in the outgoing 835. So, the rule is 10 lines in = 10
lines out = 10 lines on the next outgoing COB claim = 10 lines in the next 835,
etc.
Unbundling
If a payer unbundles a line, the payer may create a situation where it's 10 lines
in = 11 lines out. This is acceptable in the 835 (again, see the unbundling
example). However, for the next COB 837, that 837 still has 10 lines. The
unbundling is shown by running the 2430 loop twice under the unbundled 2400 line.
So, in the case where one payer unbundled a line, the claim would look like this:
10 lines into Payer A (837) = 11 lines out of Payer A (835) = 10 lines into Payer
B (the COB 837 where the 2430 loop is run twice under the unbundled 2400
loop/line) = 10 lines out of Payer B (assuming B didn't unbundle any lines in
their 835), etc.
If a payer splits a claim, the equation may be altered to a two (or more) step
process like this:
10 lines in = 5 lines out on Monday
= 5 (more) lines out on Friday
However, in the end, all 10 lines come back to the provider even if it is in
several 835s.
The net result is that all payers past the prime can see how each line was paid
(assuming the claim was adjudicated at the line level). If a payer 'didn't pay'
on a line, the line is still included in the 835 with zero payment and the
appropriate claim adjustment reason code explaining why the line was adjusted to
"0".
Does this make sense?
j
[EMAIL PROTECTED] wrote:
> In reviewing the COB white paper today on the business issue call, an issue
> came up that I wanted to see if any of you had thought about this.. or.. if
> you are on an X12 workgroup.. had they thought about this. The issue is that
> if a claim has more than one line. Line 1 may be paid out as Primary and
> Secondary while line to may only have a Primary Payer. One example of when
> this is common is when line one has a date range and during that date two
> insurance companies have coverage but the other lines have dates when there is
> only a single payer.
>
> The way to resolve this is to add information to the line level that allows
> payers to respond how they paid or split the claim into multiple claims. One
> claim would show line one and the other claim would have the other lines for
> that claim
>
> Thanks!
>
> Jonathan Showalter
> Omaha NE USA
> 402-343-3381
> [EMAIL PROTECTED]
>
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