Explanation of Benefits / Remittance Advice (835) Technical Advisory Group (TAG)
MEETING SCHEDULE:
Meeting Date: Tuesday, February 16, 2016
Meeting Time: 1:00 P.M. to 2:30 P.M. Central Time
Meeting Location: Teleconference ONLY
AUDIO INSTRUCTIONS:
Phone in number is: 1-712-832-8300
Conference code: 337213
To mute or unmute your own line: *6
WEBEX INSTRUCTIONS:
1. To start the WebEx session, go to: https://health-state-mnustraining.webex.com
2. Under “Attend a Session” click “Live Sessions”
3. Click on the session for “AUC EOB/Remit TAG Meeting”
4. Provide your name, email address, and type the following password: Eob2010!
(the exclamation point is part of the password)
5. Click “Join now”
AGENDA:
1.
Facilitators: Pete Anderson, Lisa Wichterman
Minute Taker: Lisa Wichterman
2.
AUC Antitrust Statement - http://www.health.state.mn.us/auc/antitrust.pdf
3.
Welcome and Introductions:
Please email attendance to Lisa Wichterman [email protected]
4.
Approve previous minutes.
Members Include:
Aetna ◊ Aging Services of Minnesota ◊ Allina Hospitals and Clinics ◊ American Association of Healthcare Administrative Management ◊
Blue Cross Blue Shield of MN ◊ Care Providers of Minnesota ◊ CentraCare Health System ◊ Children’s Hospitals and Clinics ◊ CVS Pharmacy
◊ Delta Dental of MN ◊ Fairview Health Services ◊ HealthEast ◊ HealthPartners – Health Plan ◊ HealthPartners – Medical Group and Regions Hospital
◊
Hennepin
County
Medical
Center
◊
Mayo
Clinic
◊
Medica
Health
Plan
◊
Metropolitan
Health
Plan
◊ MN Chiropractic Association ◊ MN Council of Health Plans ◊ MN Dental Association ◊ MN Department of Health ◊
MN Department of Human Services ◊ MN Department of Labor and Industry ◊ MN Home Care Association ◊ MN Hospital Association
◊ MN
Medical
Association
◊ MN
Medical
Group Management Association
◊
MN Pharmacists
Association
◊
Noridian Administrative Services, L.L.C. - Medicare Part A ◊ Olmsted Medical Center ◊ Park Nicollet Health Services ◊ Preferred On e
◊ PrimeWest Health ◊ REM Health Inc. ◊ Sanford Health ◊ Sanford Health Plan ◊ Silverscript ◊ St. Mary’s/Duluth Clinic Health System ◊
UCare MN ◊ UnitedHealth Group ◊ University of Minnesota Physicians
Visit the AUC website at: http://www.health.state.mn.us/auc/index.html
5.
Future MN 835 CG technical updates.
Item
a Should the new workers compensation
information on payments be added to the guide?
Status
Will add link to DLI
website
6.
MN ERA best practices, continuing outreach, technical assistance, and education to
ensure understanding and proper use of the 835 and CARCs and RARCs.
Item
Status
a
Best Practice: Overpayments
11/16/15- TAG
began itemizing
scenarios
b
Best Practice: EFT
11/16/15- point to
CORE rules which
have more detail
c
Reporting charges from the original billing on a
2/16/16- Dianne
replacement claim
requested TAG
consultation
7.
Add to 835 TR3 desired features list (post-v7030).
Item
a
The ability to relay payment reduction with finer
detail to meet business needs.
8.
Industry updatesItem
a
b
c
d
9.
Status
X12
CAQH CORE
• AUC request for additional business scenario
IAIABC (Lisa)
Other updates?
Other Business
a. Any other business?
Page 2 of 3
Status
CORE survey
REFERENCE MATERIAL:
Best
Practice.Overpaymen
Dianne request.docx
AUC best
Practices: http://www.health.state.mn.us/auc/bestpractices/v5010b
p835eft.pdf
NEXT MEETING:
Meeting Date: Monday, March 21, 2016
Meeting Time: 1:00 P.M. to 2:30 P.M. Central Time
Meeting Location: Teleconference only
Page 3 of 3
Scenarios
1) Provider discovers error and informs payer
a) Claim was billed incorrectly
i) Provider corrects claim by submitting void or corrected claim via 837
ii) Provider initiates refund
(1) Provider issues paper check to payer
(2) Provider returns payer’s check without cashing it
(3) Provider waits for payer to readjudicate claim and initiate recoupment
b) Claim was billed correctly, but paid incorrectly
i) Provider notifies payer of error via phone, paper, or portal
ii) Provider initiates refund
(1) Provider issues paper check to payer
(2) Provider returns payer’s check without cashing it
(3) Provider waits for payer to readjudicate claim and initiate recoupment
c) Claim was billed correctly, but paid incorrectly due to COB
i) Provider notifies payer and patient of error via phone, paper, or portal
ii) Provider initiates refund
(1) Provider issues paper check to payer
(2) Provider returns payer’s check without cashing it
(3) Provider waits for payer to readjudicate claim and initiate recoupment
2) Payer discovers error and initiates correction
a) Claim was billed correctly, but paid incorrectly
i) Payer uses TR3 option #1
(1) Immediate reversal and correction (deduction from current 835)
ii) Payer uses TR3 option #2
(1) Payer notifies the provider outside 835 (“manual option”) –
(2) Provider initiates refund
(a) Provider issues paper check to payer– PLB 72, WO
(b) Provider waits for payer to readjudicate claim and initiate recoupment– WO
(i) TAG comments:
Provider pain point with matching PLB with reason (notification).
Difficulty using (matching) PCN.
See 2008 best practice for possible help.
iii) Payer uses TR3 option #3
(1) 835 used as notification, contains reversal and correction.
(2) Use PLB WO to prevent immediate recoupment.
(3) Provider initiates refund
(a) Provider issues paper check to payer– PLB 72, WO
(b) Provider waits for payer to readjudicate claim and initiate recoupment– WO
Hi Pete,
Could you please add the following item to our next MN AUC TAG EOB agenda on
2/16/2016.
As the 835 guide does not address replacement claim, BCBSMN would like to know
if the MN AUC they can provide any guidance on how the 835 should reflect charges
removed from the original billing on a replacement claim. We would also like to
know if any of our provider’s would have a problem auto posting their remittance
for the following business scenario below.
BCBSMN would like MN AUC direction related to the following replacement claim business scenario:
• Original claim was submitted with two service lines
o 85025 $34.00 – Line 1
o 81003 $9.00 – Line 2
• Provider submits replacement claim removing line
o 85025 $34.00 – Line 1
• Payer denies replacement claim with CARC CO129 & RARC N377, and initiates an adjustment to the
original claim.
o 85025 $34.00 – Line 1
• Payer adjust original claim with two lines, zero’s out Line 1 returning on RARC N377. No CARC is
returned on a zero line charge.
SVC^HC>81003^9^3.44
DTM^472^20151209
CAS^CO^45^5.63^^137^-.07
REF^6R^748306271
AMT^B6^3.44
SVC^HC>81003^0^0^^0^^1
DTM^472^20151209
REF^6R^738921632
LQ^HE^N377
Thank you
Dianne Hagen
Operations Business Analyst Sr | EC Operations
651-662-7407
[email protected]
Blue Cross Blue Shield of Minnesota
1750 Yankee Doodle Road | Eagan, MN 55121
Mail Route S204