Latest Validation: November 2016

BPR: Version 3.91

Worksheet Version: 071416a

Updated: April 2017, May 2017, Sept 2017, Jan 2018, November 2018, July 2019, August 2019, February 2020, March 2020, June 2020

High Impact Best Practices: 20 of 21 are met. 1 is not met.

Claim line denials reported on the 835 with CO45/N20 actually were adjudicated with CO97, not separately payable, and CO45 /N20.  These claims have CO45 with the adjusted amount and CO97 with zero amount.  Because adjustments with zero dollars are not sent in the 835s, only the CO45s are present. This is a code issue. Action to be taken:  Will be corrected.  Completion Date: This Service Request has moved from a research SR to an actual Production SR, tentatively scheduled for a November 2020 release.

Medium Impact Best Practices: 11 of 11 are met.

Aetna currently uses CARC 18 for denial situations other than “an exact duplicate claim/service line was submitted’, e.g. corrected claims. In March 2017, CO18 was returned for claims with Same Patient, Date of Service and procedure, but different rendering providers with different specialties. Action to be taken: Completed projects regarding the manual and automated processing of voided and corrected claims

• ERAs containing HMO and non-HMO claims sent in as corrections to originals should be received back as corrections to originals rather than denied as duplicates.
• Single segment correction and void claims have been addressed.
• Multi segment replacement and void claims have been addressed.

Completion Date: November 2019. 02-04: Confirmed by providers as completed.

Notes:

1. Providers would like OA23 to reflect Prior Payer(s) payments + provider adjustments. Aetna follows process outlined in X12 RFI 2143 COB Reporting.

Calculate Impact of Prior Payer (CAS*OA*23):

• Create X = 1st Plan Paid + 1st Plan Provider Write-off
• Create Y = Submitted – Aetna Patient Responsibility – Aetna Paid
• Create Z = Y – X

Impact of Primary Payer (CAS*OA*23)=

• If Z = 0, populate with X
• If Z < 0, populate with Y

Example:

CLP*815900102*2*489.8*101.5*82.29*13*PVJLS03YP0000*13*7

AMT*AU*489.8

SVC*HC:99212:25*489.8*101.5**1

DTM*472*20160528

CAS*OA*23*306.01

CAS*PR*2*82.29

REF*6R*00000000002

AMT*B6*411.43

 

X=306.01

Y=489.80-101.50-82.29 = 306.01

Z=Y-X

Z=0

2. The date reported in the Claim Received Date field (DTM*50) is the most recent date that documentation required to adjudicate the claim was received by the Aetna. It is not the date that the submitted claim was received by the health plan.
3. Explanation of Splitting of Claims

Q1. Might Aetna split 8371 claims with 18 or less lines?

A: Yes:

• 8371 claims in excess of 18 lines are split due to line limits on our auto adjudication system.
• 8371 claims may split if line splits or unbundling occur that result in more than 18 lines.
• Claims are also split to expedite partial payment for lines finalized vs lines held for high dollar amount authorization or lines pended for clinical review.
• Claims are split if the total billed amount exceeds the auto adjudication limit of $99,999.99.

Q2. Might some of the claim splits be denied as duplicates?

A: Not intentionally.

• If a claim is manually processed there is a margin of human error that could occur.
• The auto adjudication system that may split a claim assigns sequence numbers to the original claim id. Sequential suffixes of the original claim id are considered the same claim.

Latest Validation: Sept 2014

BPR: Version 3.4

Worksheet Version: 042214a

High Impact Best Practices: 16 of 20 are met. 4 are not met.

• A subscriber loop is not always sent when the patient is the dependent.  Payment is under subscriber name/ID, but showing as the patient (QC).  Action to be Taken: None Reported by the health plan.
• In the PLB, Adjustment Group Codes reported on the reversal are not always the same as the adjustment Group Codes reported on the original adjudication, e.g. CO originally sent and OA was reported on the reversal.  Action to be Taken:None Reported by the health plan.
• When charge are denied with CO59, a contractual allowance is sometimes inappropriately  taken (CO45) Action to be Taken: None Reported by the health plan
• Claim Status Code of ‘4’ is inappropriately used in denial situations other than when the patient/subscriber is not recognized by the health plan. Action to be Taken: None Reported.

Medium Impact Best Practices: 7 of 10 are met. 3 are not met.

• CARC 18 is sometimes used inappropriately when a corrected claim is sent, i.e. a corrected claim will be denied as a duplicate.  Action to be Taken: None Reported by the health plan.
• When there is a PLB for interest, the PLB does not always contain patient control number.   Action to be Taken: None Reported by the health plan.
• A Claim Received Date is not put in the DTM segment of Loop 2100.  Action to be Taken: None Reported by the health plan.

Latest Validation: May 2014

BPR: Version 3.4

Worksheet Version: 042214a

Updated: July 9, 2015

High Impact Best Practices: 19 of 19 are met.

Medium Impact Best Practices: 10 of 11 are met. 1 is not met.

In situations of dual Asuris coverage, there is no TT indicator in either file showing that claims are being crossed over. Action to be Taken: None.  Due to system limitations this is not something we will implement.

Note:  The Claim Received Date that is put in DTM*050 will be the date that the claim was received by Asuris.

Latest Validation: June 2018

BPR: Version 3.91

Worksheet Version: 071416a

Updated: July 2018, March 2019

High Impact Best Practices: 5 of 21 are not met. 16 are met.

• In the PLB, reversals are displayed after the new reprocessed payment, rather than before per the BPR. Action taken: No action will be taken as this is not a TR3 requirement. Completion Date: None
• The 835 does not always balance at the Claim and Transaction levels. Action taken: This has been acknowledged as a problem and will be fixed. It has not yet been given a fix priority. Completion Date: None
• CAS03 values are not always = 0. Action taken: This has been acknowledged as a problem and will be fixed. It has not yet been given a fix priority. Completion Date: None
• On secondary claims, CHPW does not always appropriately report their financial impact using a CO/PI 45 AND the financial impact of the previous payer(s) by appropriately using the OA23. Action taken: The IT department has identified a fix for this issue. The engineers will code the update that is needed to fix the problem. It has not yet been given a fix priority. Completion Date: None
• Status code of 4 is used even when the patient is found in the system. In these cases, a Status code of 1 should be used if CHPW is primary and a 2 should be used if CHPW is secondary. Action taken: This has been acknowledged as a problem and will be fixed. It has not yet been given a fix priority. Completion Date: None

Medium Impact Best Practices: 11 of 11 are met.

Note: The Claim Received Date that is put in DTM*050 will be the date that the claim was received by CHPW.

Latest Validation: February 2019

BPR: Version 3.91

Worksheet Version: 071416a

High Impact Best Practices: 20 of 22 are met. 2 are not met.

• Returning 837 information on the 835: For Allegiance claims, the patient’s name is sometimes returned on the 835 rather than the subscriber name. Action taken: Being researched – ticket number SD21506556. Completion date: TBD
• CO45 and OA23 reporting: The claim engine is not identifying the COB information correctly so that on secondary claims CO45 reports the total service/claim charge amount and duplicates provider adjustment amount that have resulted from the prior payor adjudication, which is consistent with the WPC-EDI usage definition for CARC45. Action to be taken: Problem identified in claim engine the ticket created – SD21734174. Completion date: TBD

Medium Impact Best Practices: 12 of 12 are met.

Notes

• Cigna reports the billing provider name that is in the claims processing system that produced the 835. However, the billing provider name may be different across the different claims processing systems. If/when this occurs, provider organizations should work with their Experience Manager to have their provider data updated in Claims processing system(s).
• The Claim Received Date that is put in DTM*050 is the date that the claim was received by Cigna.

Latest Validation: Sept 2014

BPR: Version 3.4

Worksheet Version: 042214a

High Impact Best Practices: 15 of 20 are met. 5 are not met.

In reporting information in the PLB:

• PLB03-2 may contain a date rather than the patient control number.  Action to be Taken: None Reported by health plan.
• When processing payment recovery, a partial payment may be taken back rather than taking back the entire payment and reprocessing the claim.  Action to be Taken: None Reported by health plan.
• The correction is displayed prior to the reversal.  Action to be Taken:  None Reported by health plan.
• The adjustment Group and Reason Codes for the reversal are not always the same as were used on the original adjudication.  Action to be Taken: None Reported by health plan.

Claim Status Code of ‘4’ is used in denial situations other than when the patient/subscriber is not recognized by the health plan. Action to be Taken: None Reported by health plan.

Medium Impact Best Practices: 8 of 10 are met. 2 are not met.

• The REF*CE segment is not included on the 835.  Action to be Taken: None Reported by health plan.
• A Claim Received Date is not put in the DTM segment of Loop 2100.  Action to be Taken: None Reported by health plan.

Latest Validation: December 2017

BPR: Version 3.91

Worksheet Version: 071416a

Updated: January 2019, March 2019

Lines of Business: All

High Impact Best Practices:  20 of 21 are met.  1 is not met.

• CO45 not used correctly

For dual coverage reporting, the primary payer’s contractual allowance is not being reported on the secondary claim portion of the 835. The secondary write off is being reported as a Contractual Allowance (CO). Per the TR3 and the BPR, the primary payer’s contractual allowance should be reported as an Other Adjustment (OA) and any secondary payer’s write off as a CO. Action to be taken: Not yet in the priority queue. Completion Date: None

Medium Impact Best Practices:   10 of 11 are met.  1 is not met.

• Use of the REF*CE

The REF*CE does not contain the contract that applies to the claim (which should be the same contract name that is contained in the 271 response). Also, Options file contain both the old GHO and KPS. Action to be taken: SR629 – Not yet prioritized. Completion Date: None

Note:  The Claim Received Date that is put in DTM*050 will be the date that the claim was received by KP.

Latest Validation: August 2013

BPR: Version 3.2

Worksheet Version: 041613a

Updated: February 2014

High Impact Best Practices:   16 of 17 are met.  1 is not met.

837-835 Information

• Alpha prefix of the Subscriber ID is not always returned on the 835.  Action to be taken: To be fixed, in analysis and design. Date TBD
• When 2 claims (each with a different patient control number) for the same patient, for similar services and on same day – are being bundled, with the 2 different patient control numbers (837, CLM01) they are combined in the 835 and reported in the CLP01 as ‘number/number’.  Action to be taken:  Solution being researched and discussed internally. Date TBD

Medium Impact Best Practices:   11 of 11 are met.

Note:  The Claim Received Date that is put in DTM*050 will be the date that the claim was received by Lifewise.  Should a request for additional information be sent out during adjudication, but the information is received after the claim is closed/rejected, a new claim will be opened and DTM*050 will contain the date that the new information was received.

Latest Validation: November 2014

BPR: Version 3.5

Worksheet Version: 091514a

Updated: December 2017, November 2018, September 2019

High Impact Best Practices:   18 of 20 are met.  2 are not met.

• PLB:  When the FB identifier is used, PLB adjustments inappropriately net to zero. This has been identified as a defect in vendor software.  Action: Will not fix until the implementation of 7030 transactions.
• For institutional claims that are processed as secondary from Medicare, line item detail is not reported. (B.5). Action to be Taken: None – Compliant with TR3.

The information was returned correctly.  For WA State Medicaid, Outpatient Medicare Crossovers are priced at header, therefore (per the TR3) no line level information will be returned on the RA.

Medium Impact Best Practices:   10 of 11 are met.  1 is not met.

• Initially Reported in April 2012: PLB – Patient control number is not contained in the designated fields. Action to be taken: None – Compliant with TR3.

No date is put into Claim Received Date (DTM segment of Loop 2100) as prompt pay discounts do not apply to Washington Medicaid.

Latest Validation: June 2016

BPR: Version 3.9

Worksheet Version: 051415a

High Impact Best Practices:   18 of 20 are met.  2 are not met.

• Patient Name sent on 837 is not returned on 835.  Action to be taken: None – as current approach is compliant with TR3

The TR3 states that NM101, NM102, NM108, and NM109 are required, and the other elements in that segment are situational.  NM103 (patient name) would be required if necessary for identification of the provider, but since the individual NPI in NM109 identifies the provider, NM103 would remain situational.

• PLB – When a reversal/correction amount for an account within that remit exceeds the provider paid amount, a WO should be used rather than an FB.  (Currently, an FB is being used with a PLB – which is not compliant – but is preferable to an FB without the PLB.).  Action to be taken: None

Medium Impact Best Practices:   10 of 11 are met.  1 is not met.

The REF*CE was not used to report the contract.  Action to be taken: None – as current approach is compliant with the TR3

The TR3 states that CE would be used in the instance of a PPO, or in the instance of multiple contract types being used by one payer.  Since there are not PPOs or sub-contract types used by Medicare Part B of Washington (or other states), Medicare would not utilize the REF*CE segment.

Latest Validation: March 2015

BPR: Version 3.6

Worksheet Version: 091514a

Updated: August 2017

High Impact Best Practices: 20 of 21 are met. 1 is not met.

On remittances for secondary claims, the OA23 amount is not always calculated correctly.  Action to be taken: The OA 23 will reflect the primary payer’s payments and/or adjustments.  To be completed: Change will be in production by 4Q2017.

Medium Impact Best Practices: 10 of 10 are met.

Note:

The REF*CE segment contains the Benefit Plan ID. The attached table matches the PlanID to the Plan Description.

Latest Validation: August 2013

BPR: Version 3.2

Worksheet Version: 041613a

Last Status Reported: June 2018, December 2018

High Impact Best Practices: 16 of 17 are met. 1 is not met.

837-835 Information

• When 2 claims (each with a different patient control number) for the same patient, for similar services and on same day – are being bundled, with the 2 different patient control numbers (837, CLM01) they are combined in the 835 and reported in the CLP01 as ‘number/number’.  Action to be taken:  A 2019 Corrected Claims Project (Operations) is underway, this issue will be one of the ones to be explored. Date TBD

Medium Impact Best Practices: 11 of 11 are met.

Note:  The Claim Received Date that is put in DTM*050 will be the date that the claim was received by Premera.  Should a request for additional information be sent out during adjudication, but the information is received after the claim is closed/rejected, a new claim will be opened and DTM*050 will contain the date that the new information was received.

Latest Validation: May 2014

BPR: Version 3.4

Worksheet Version: 042214a

Updated: July 9, 2015

High Impact Best Practices: 19 of 19 are met.

Medium Impact Best Practices: 10 of 11 are met. 1 is not met.

In situations of dual Regence coverage, there is no TT indicator in either file showing that claims are being crossed over.  Action to be Taken: None.  Due to system limitations this is not something we will implement.

Note:  The Claim Received Date that is put in DTM*050 will be the date that the claim was received by Regence.

Latest Validation: December 2016

BPR: Version 3.91

Worksheet Version: 071416a

High Impact Best Practices: 22 of 22 are met.

Medium Impact Best Practices: 10 of 10 are met.

Latest Validation: February 2017

BPR: Version 2.9

Worksheet Version: 091312a

High Impact Best Practices: 17 of 17 are met.

Medium Impact Best Practices: 11 of 11 are met.

Note: For Institutional claims that are sent electronically or on paper, only claim level payment information will be reported on the 835

Latest Validation: July 2015

BPR: Version 3.8

Worksheet Version: 051415a

Updated: August 2017, November 2017, December 2018, August 2019, September 2019, December 2019

High Impact Best Practices: 20 of 21 are met. 1 is not met.

When an 837 is submitted for a patient that cannot be found as a member in UHC’s system, ‘member unknown’ is reported on the 835 rather than the patient’s name that was submitted on the 837. Action to be taken: Initially completed on Q1 2019. Issues identified during provider revalidation. Under development at UHC. Completion Date: 1Q2020

For their Managed Medicaid product, when multiple patient IDs are sent on an 837, the 835 does not always reflect the IDs back as they were sent on the claim. Action to be taken: None – See Note 1 below. Completion Date: Not Applicable

Medium Impact Best Practices: 8 of 10 are met. 2 are not met.

• CARC 18 is used to deny a corrected claim as well as a claim that is an exact duplicate of a previously submitted claim. Action to be taken: Only exact duplicate claims with no changes to previous submissions should be coded as CARC 18. UHC will communicate TR3 recommendations and best practice findings with UHC claims processing division to identify if update will be implemented. Assessment Completion Date: Completion validated by Providers 10-12-17, BUT

Sent claims are sometimes denied with CARC 18 RARC N522 and later reversed and paid, sometimes on the same remit. Action to be taken: Awaiting UHC Response. Completion Date: Completion validated by Providers 9/2019.

• The REF*CE segment was not used to report the contract that that applies to the claim. Action to be taken: Initially completed on 07/2019. Issues identified during provider revalidation. Under development at UHC. Completion Date: 12/14/2019.
• The Claim Received Date is not reported in DTM segment of Loop 2100. Action to be taken: Update to be implemented. Completion Date: Completed on 07/2019 & validated by Providers 09/2019.

Notes:

1. If the product is Managed Medicaid, UHC’s 835 will always return the Medicaid ID with the qualifier “MR” in NM108 and will send subscriber id with Ref*1W
2. NPI numbers maintained in the UHC database are not always correct, resulting in inappropriate NPI numbers being reported in the payee loop (1000b) on the 835 transaction.  (UHC pulls from their database rather than using the number submitted on the 837.  The number submitted on the 837 is only reported in loop 2100 (Service Provider Name -NM109))  *** This is not a transaction issue ****
3. The Patient Control Number is reported on the 835 in the PLB section with CS and WO.  However the formatting is not consistent:
   • CS^ Pat Ctrl, date
   • WO^ date, Pat Ctrl
4. The 835 will not match what was sent on the 837 when charge lines are bundled and split out for reimbursement. All charge lines are returned on the 835 with the original procedure listed in SVC06, but the line item control number doesn’t match the original claim. Action to be taken: None – Currently when 2 service lines are bundled into one, the line item control number from the original service line is returned on subsequent split lines. For example, the line item control number tied to the first CPT will be returned on both the bundled lines. Completion Date: N/A

Latest Validation: January 2014

BPR: Version 3.3

Worksheet Version: 090313a

Last Status Reported: April 4, 2017

UHC-West is handling take-back recovery at the claim level rather than using a PLB (which is the provider-preferred approach).

High Impact Best Practices:   17 of 17 are met.

Medium Impact Best Practices:   11 of 11 are met.

Notes:

1. The Payer Technical Contact Information in the PER segment is too general to be of use when trying to get ahold of the person that can help with a specific issue.   UHC is taking operational steps to ensure internal staff can provide assistance when providers contact UHC for assistance using the contact information provided in the PER segment.
2. The Claim Received Date that is put in DTM*050 will be the date that the claim was received by UHC-West.
3. REF*CE does not contain identifying information about the contact under which the claim was adjudicated. However, since there is only one relevant contract in Washington State, this does not present any problems for WA providers.

Latest Validation: May 2016

BPR: Version 3.91

Worksheet Version: 051415a

Updated: October 2017

High Impact Best Practices:   20 of 20 are met.

Medium Impact Best Practices:   11 of 11 are met.

Note:

Group Code “CO” is used with CARC 18 which is appropriate in cases of Workman’s Compensation.