Explanation of Benefits / Remittance Advice (835) Technical Advisory Group (TAG)
MEETING SCHEDULE:
Meeting Date: Monday, March 21, 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 ◊ PreferredOne
◊ 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.
a
Item
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
3/21/16- TAG will
continue itemizing
scenarios
b
Best Practice: EFT
11/16/15- point to
CORE rules which
have more detail
7.
Add to 835 TR3 desired features list (post-v7030).
Item
a
8.
The ability to relay payment reduction with finer
detail to meet business needs.
Industry updatesItem
a
b
c
d
9.
Status
X12
CAQH CORE
IAIABC (Lisa)
Other updates?
Other Business
a. Any other business?
Page 2 of 3
Status
REFERENCE MATERIAL:
MM 21616.docx
Best
Practice.Overpaymen
NEXT MEETING:
Meeting Date: Monday, April 18, 2016
Meeting Time: 1:00 P.M. to 2:30 P.M. Central Time
Meeting Location: Teleconference only
Page 3 of 3
AUC EOB/Remit TAG Meeting Minutes February 16, 2016 1:00 pm
Agenda Item
Discussion
Action
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.
5. Future MN 835 CG technical updates.
6. MN ERA best practices, continuing outreach,
technical assistance, and education to ensure
understanding and proper use of the 835 and
CARCs and RARCs.
No formal minutes were taken for the
last meeting in November 2015.
Proposing having a link to the DLI
website in the Companion Guide.
Reviewed overpayment scenarios and
possible results.
• Provider discovers error
• Claim billed correctly, but paid
incorrectly
• Payer discovers error and
initiates correction.
Refund by paper check
Return original uncashed check
Provider waits for payer to adjudicate
the claim.
TAG will carry this forward to the next
meeting to draft best practices.
Agenda Item
7. Replacement claims
8. Industry updates
9. Other Business
Discussion
Action
TAG discussed scenarios regarding COB
overpayments and credits.
The ASC X12 5010 835 guide does
provide examples of COB situations.
TAG created COB examples were the
secondary payer overpays.
BCBS is looking for direction with
replacement claims so providers can
auto posts the 835s. Issue is when
providers resubmits a claim removing a
line item. Providers indicate the
replacement claim goes out with a new
account number.
IAIABC ProPay committee meets
2/17/16.
NCVHS hearings are today on
attachments
DLI has proposed legislation to move
effective date of the 275 to 1/1/17.
None
BCBS received guidance from the
providers on what their systems can
receive without rejections for
replacement claims.
Next Meeting:
Monday March 21, 2016
1:00 PM – 2:30 PM Central Time
Teleconference only
Attendees:
David Haugen
Lisa Wichterman
Dianne Hagen
Tracy Wry
Jessica Evans
Michelle Dinkins
Julie Saba
Pete Anderson
Brenda
Darryl Ross
Megan Green
Jessica Evans
Deb Sommer
Donald Bechtle
Mary Hall
Sonya May
Leslee Smithers
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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
CLP 22 Reversal of original claim (void or correction)
CLP 1 Correction claim (correction)
PLB WO $ii) Provider initiates refund
(1) Provider issues paper check to payer
PLB 72 $- and WO $+
(2) Provider returns payer’s check without cashing it
Not recommended
(3) Provider waits for payer to readjudicate claim and initiate recoupment
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
b) Claim was billed correctly, but paid incorrectly
i) Provider notifies payer of error via phone, paper, or portal
no 835
i) Payer readjudicates claim
CLP 22 Reversal of original claim
CLP 1 Correction claim
PLB WO $ii) Provider initiates refund
(1) Provider issues paper check to payer
PLB 72 $- and WO $+
(2) Provider returns payer’s check without cashing it
Not recommended
(3) Provider waits for payer to readjudicate claim and initiate recoupment
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
c) Claim was billed correctly, but reported incorrectly in 835 due to COB
total charge is $200
Primary payer pays $50 remaining PR is $50, allowance is $100
Secondary payer pays $25 OA*23*150, often not reported as 150 (could be 50=primary
paid), PR $25, if not reported as $25, requires provider to investigate to determine if
payment is correct
Example of correct secondary 835
CLP*x*1*200*25*25~
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CAS*OA*23*150~ reflects primary payment and allowance
CAS*PR*1*25~
d) Claim was billed correctly, but reported incorrectly in 835 due to COB
Total billed $200
Primary payer pays $100 CO*45*75
PR*3*25, allowance is $125
Secondary payer pays $125
CO*45*75
OA*23*100
Secondary should have paid $25
secondary payer doesn’t need refund
Example of overpaid
CLP*x*1*200*25*25~
CAS*OA*23*150~ reflects primary payment and allowance
CAS*PR*1*25~
Correction and recoupment of any overpayment handled as in 1 (a) or 1(b)
(1)
2) Payer discovers error and initiates correction
c) Claim was billed correctly, but paid incorrectly
i) Payer uses TR3 option #1
(1) Immediate reversal and correction (deduction from current 835)
CLP*22
CLP*1
PLB FB $- is possible if too little $$ to satisfy recoupment
ii) Payer uses TR3 option #2
(1) Payer notifies the provider outside 835 (“manual option”) –
(2) Provider initiates refund
(a) Provider issues paper check to payer–
PLB 72 $-, WO $+
(b) Provider waits for payer to readjudicate claim and initiate recoupment–
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
(i) TAG comments:
Provider pain point with matching PLB with reason (notification).
Recommend using patient account number
When WO identifier is Payer control number, instead of provider’s patient
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account number, there is difficulty matching.
See 2008 best practice for possible help.
iii) Payer uses TR3 option #3
(1) 835 used as notification, contains reversal and correction. Use PLB WO to
prevent immediate recoupment
CLP*22
CLP*1
PLB WO $-
(2) Provider initiates refund
(a) Provider issues paper check to payer– PLB 72, WO
PLB 72 $- and WO $+
(b) Provider waits for payer to readjudicate claim and initiate recoupment–
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
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