Secondary Electronic Claims

Andrea Pomazal

Outline

• What is a Secondary Electronic Claim

• What information is required

• Where does the information report in Claims Manager

• CAS Segments

• Secondary Claim Balancing

• Secondary COB Balancing Summary

• Questions

Test your Knowledge #1

What is a Secondary Claim?

Test your Knowledge #2

What are the 4 basic edits Medicare is performing on claims?

Test your Knowledge #3

How do you identify secondary claims in the application?

Test your Knowledge #4

What is the COB Summary Report and

how do you access it within the application?

Test your Knowledge #5

What is a CAS segment?

What is a Secondary Claim?

• Subscriber has more then one insurance company that will pay for medical services

• 1st Insurance Company has adjudicated claim

• Provider is requesting payment for remaining balance on claim from the second insurance

What information does the Secondary payer need?

• Primary Insurance Information

• Primary Insurance Amount Paid

• Date Claim was Adjudicated

• Payment Adjustments

Where does this information report on the claim?

• Loop 2320 “Other Subscriber Information”

– Primary Insurance Amount Paid

– Primary Insurance Information

• Loop 2330B Other Payer Information

– Date Claim was Adjudicated

• Loop 2430 “Line Adjudication Information”

– Payment Adjustments

What is a CAS Segment?

• Used to report the payment adjustment amounts

• Claim Adjustment Group Codes http://www.wpc-edi.com/content/view/701/397/

• Claim Adjustment Reason Codes

http://www.wpc-edi.com/content/view/695/1

Balancing Requirements

• Claim Primary Paid Amount

– The Sum of all line items payment amount (SVD02)=Claim’s Primary Payment Amount (AMT*D)

• Claim Primary Payer Allowed Amount

– The sum of all line items approved amount (AMT*AAE)=Claim’s Primary Payer Allowed Amount (AMT*B6)

Balancing Requirements continued

• Total Claim Charge Amount

– The Primary Paid Amount (AMT*D)+ Claim Level Adjustments (CAS segments) + Line Level Adjustments (CAS segments)= Claim Amount (CLM02)

• Line Item Charge Amount

– Line Item Primary Paid Amount (SVD02)+Line Level Adjustment (CAS Segment)=Line Item Charge Amount (SV102)

Fixing a Secondary Claim

Questions