Secondary Electronic Claims
Transcript of Secondary Electronic Claims
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