Bill, Is this a 'double-indemnity' example? When I co-chaired the WG7 on COB, I heard of such benefit packages. They are few and far between and in my health plan experience, such contracts are not written anymore. However, if they currently exist and are renewable, I believe the subscriber could actually be reimbursed by multiple insurers for the same, fully paid benefit. When there is no Coordination of Benefits and no max-reimbursement limitations I believe you have a valid example. In that case, it would be more appropriate to follow the latter outcome...create the CAS segment and respond with the reason code describing why you did not pay the claim (your example was that the filing time limit was exceeded). That's my opinion. Chris
-----Original Message----- From: Sayman, William [mailto:[EMAIL PROTECTED]] Sent: Wednesday, May 01, 2002 8:45 AM To: '[EMAIL PROTECTED]' Subject: 835 - Medicare Paid in Full We currently receive claims for secondary payment, where Medicare made the primary payment. We are trying to determine the appropriate way to create the 835 CAS segment for the following situation: The provider charged $100.00 for the service and Medicare paid that service in full. We then receive that claim from the Medicare Intermediary on an 837COB transaction. For some reason (timely filing, for example) we do not even consider paying that service and reject the claim line. Would it be more appropriate to create the CAS segment with an adjustment group code of PI (payer initiated) and an adjustment reason of 23 (paid by another carrier), or would it be appropriate to create the CAS segment with an adjustment group code of PI and an adjustment reason of 29 (time limit for filing has expired). Basically, is it more important to a provider to know the payment by the other insurer (Medicare), or would they want to know the appropriate reject reason for which we denied the claim. If anyone has discussed this situation, or has an opinion on this, please let me know. Thanks in advance, Bill Sayman
