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David,
Correct, IF you get an 835. Since there is no way an 835
can be requested in the 837 transaction (you can explicitly request a paper EOB;
if you do not, it does not automatically mean that an 835 will be returned), the
set-up to return an 835 may involve steps outside the standard transaction sets
to create a provider profile in the payer's database indicating the
request. Therefore, some payments may involve paper EOBs. Some
payers are notorious for the lack of information on thier paper
EOBs.
Also, an 835 responding to an 837I may not contain line-item
remittance information, since reimbursement can be based on the DRG rather than
the line-item details.
The opinions expressed here are my own and not necessarily the opinion of
LCMH.
Douglas M. Webb Computer System Engineer Little Company of Mary
Hospital & Health Care Centers [EMAIL PROTECTED]
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----- Original Message -----
Sent: Monday, September 22, 2003 08:54
AM
Subject: RE: COB Balancing
Correct me if I'm
incorrect, but 835's returning payment information on professional claims are
required to return service line information are they not? Therefore
there has to be SOME service line information, even it's nothing more than one
payment.
Thanks
Dave
David G. Foulke
Software Development
Dairyland Healthcare
Solutions
320-634-5331
[EMAIL PROTECTED]
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-----Original
Message-----
From: Doug Webb
[mailto:[EMAIL PROTECTED]
Sent: Monday, September 22, 2003 8:16
AM
To: WEDI SNIP Transactions
Workgroup List
Cc: WEDI SNIP
Transactions Workgroup List
Subject: Re: COB
Balancing
Also, how can the Clearinghouse possibly
know what the EOB or 835 you received contained?
As you pointed out, the 837 must
accurately report what was received from the primary
payer.
Requiring service-line level adjustments
when you do not have service-line level information is just plain
wrong.
The opinions expressed here are my
own and not necessarily the opinion of LCMH.
Douglas M. Webb
Computer System
Engineer
Little Company of Mary Hospital & Health Care Centers
[EMAIL PROTECTED]
"This electronic message may
contain information that is confidential and/or legally privileged. It is
intended only for the use of the individual(s) and entity(s) named as
recipients in the message. If you are not an intended recipient of the
message, please notify the sender immediately, delete the material from
any computer, do not deliver, distribute, or copy this message, and do not
disclose its contents or take action in reliance on the information it
contains. Thank you."
----- Original Message -----
Sent: Monday,
September 22, 2003 07:16 AM
Subject: Re: COB
Balancing
Jenn, what is reported on the
remittance advice is what must be reflected
on the 837 secondary/tertiary
claim(s). The 835 Implementation Guide on
page 20 near the bottom
in the description for Amount 8 the note indicates
the amount can be
transmitted in the Claim Adjustment Segment and/or the
Service Adjustment
Segment. Additionally, the third paragraph on page 21
states "When
the Service Payment Information loop is present, adjustments
are reported
in either (emphasis added) the Claim Adjustment or the Service
Adjustment
Segments but not in both. The example provided basically points
out
that the same adjustment should not be repeated at both the claim
and
service level. Also the IG notes the preference that the
adjustment be
shown at the service level when possible.
I do not
see how a clearinghouse can demand that adjustments be shown at
the
service level if the prior payer reported the adjustments at the
claim
level. At the same time you might as well be prepared to
report service
level adjustments when a payer adjudicates and returns
service level
adjustments.
Robert C. Pozniak
NYS Department of
Health
HIPAA Practice
Group
"Jones,
Jennifer"
<[EMAIL PROTECTED]
To: "WEDI SNIP Transactions Workgroup
List"
ech.com>
<[EMAIL PROTECTED]>
cc:
09/19/2003 03:55
Subject: COB
Balancing
PM
Please respond
to
"Jones,
Jennifer"
I'm sure it is late in the game to asking about
this but I haven't had this
request until recently ?
I have
aClearinghouse who is requesting COB information at both the claim
and
line level.I have not been doing this for other payers so now I'm
forced
to change it (for one situation).
I'm frustrated because I've gotten
this far in the game and been able to
successfully send COB claims with
this information at only the claim level.
Iguess, before I do it, I
want to make sure I should ?
Thanks ---
jenn
____________________
Jennifer Lynne Jones
Sanitas
Product Manager>
Pinpoint Technologies
Boulder, CO
80301
303-801-1829 (Direct)
303-801-0001 (Fax)
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