Explanation of Benefits / Remittance Advice (835) Technical Advisory Group (TAG)
MEETING SCHEDULE:
Meeting Date: Monday, April 18, 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 our 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
4/18/16- 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:
http://www.health.state.mn.us/auc/bestpractices/v5010bp835eft.pdf
NEXT MEETING:
Meeting Date: Monday, May 16, 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 March 21, 2016
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.
Minutes approved as presented
DLI will add link to website with
updated guide and information
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.
7. Add to 835 TR3 desired features list (post-
TAG reviewed the overpayment
scenarios. Examples of 835s are
helpful for clearer understanding of
the scenarios and the process.
TAG drafted examples of 835s to
compliment the overpayment
scenarios to be included with the best
practices. Pete will send out the
examples worked on today to the TAG
to ensure the examples are correct for
each individual scenario.
No discussion
v7030).
8. Industry updates
9. Other Business
10.
No discussion
None
Next Meeting
Agenda Item
Attendees:
Pete Anderson
Lisa Wichterman
Annie Brannan
Daryl Ross
Dawn Tessmer
Deb Sommer
Jeff Majerle
Faye Ostroot
Greg Maurer
Discussion
Julie Saba
Leslee Smithers
Sonya May
Tracy
Jennifer Maki
David Haugen
Shannon House
Gerry Soder
Donald Bechtel
Action
Monday April 18, 2016
1:00 PM – 2:30 PM Central Time
Teleconference only
835 Overpayment Recovery
Provider
discovers error
Payer discovers
payment error
Billing error
Billing error or
payment error?
Payment error
Provider submits
corrected claim
837
1- Notify provider via 835
with immediate recovery
Report
CLP 22 $and CLP 1 $+
Sufficient funds
in payment?
Provider notifies
payer of error
Payer
readjudicates caim
and determines
overpayment
Payer
overpayment
recovery
option?
3- Notify provider via 835
with delayed recovery
2- Notify provider outside 835
with delayed recovery
(not used for billing errors)
no
Report
CLP 22 $and CLP 1 $+
Payer notifies
provider outside
835
Add PLB WO $-
Send 835
Example 4
yes
Add PLB FB $-
Send 835
Example 1
(Time passes)
Send 835
Example 2
Provider sends
refund?
no
Report
PLB WO $+
(Time passes)
yes
Sufficient funds
in payment?
Add PLB FB $+
Report
PLB 72 $and PLB WO $+
yes
Send 835
Example 3
Send 835
Example 5
Send 835
Example 6
no
Add PLB FB $-
Send 835
Example 7
Time passes
Add PLB FB $+
4/14/2016
Send 835
Example 8
1
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
Payer readjudicates claim:
CLP 22 Reversal of original claim (void or correction)
CLP 1 Correction claim (correction)
(1) Immediate recoupment- sufficient money available – Example 1
no PLB needed
(2) Immediate recoupment- insufficient money available – Example 2&3
PLB FB $(3) Delayed recoupment – Example 4
PLB WO $(a) Provider initiates refund
(i) Provider issues paper check to payer – Example 5
PLB 72 $- and WO $+
(ii) Provider returns payer’s check without cashing it
Not recommended
(b) Provider waits for payer to initiate recoupment – Example 6 or Example 7&8
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
b) Claim was billed correctly, but paid incorrectly
i) Provider notifies payer of error via phone, paper, or portal
no 837
ii) Payer readjudicates claim
CLP 22 Reversal of original claim
CLP 1 Correction claim
(1) Immediate recoupment- sufficient money available – Example 1
no PLB needed
(2) Immediate recoupment- insufficient money available – Example 2&3
PLB FB $(3) Delayed recoupment – Example 4
PLB WO $(a) Provider initiates refund
(i) Provider issues paper check to payer – Example 5
PLB 72 $- and WO $+
(ii) Provider returns payer’s check without cashing it
Not recommended
(b) Provider waits for payer to initiate recoupment – Example 6 or Example 7&8
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
1
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 claim
CLP*x*1*200*25*25~
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)
2
2) Payer discovers error and initiates correction
a) Claim was billed correctly, but paid incorrectly
i) Payer uses TR3 option #1
Payer readjudicates claim
CLP 22 Reversal of original claim
CLP 1 Correction claim
(2) Immediate recoupment- sufficient money available – Example 1
no PLB needed
(3) Immediate recoupment- insufficient money available – Example 2&3
PLB FB $ii) Payer uses TR3 option #2
Payer notifies the provider outside 835 (“manual option”)
(1) Provider initiates refund
Provider issues paper check to payer – Example 5
PLB 72 $-, WO $+
(2) Provider waits for payer to initiate recoupment – Example 6 or Example 7&8
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
TAG comments:
Provider pain point with matching PLB with reason (notification).
Recommend using patient account number
When WO identifier is Payer control number, instead of provider’s patient account number, there is
difficulty matching.
See 2008 best practice for possible help.
iii) Payer uses TR3 option #3
(1) 835 used as notification, contains reversal and correction. Use PLB WO to prevent immediate
recoupment – Example 4
CLP*22
CLP*1
PLB WO $(a) Provider initiates refund – Example 5
Provider issues paper check to payer– PLB 72, WO
PLB 72 $- and WO $+
(b) Provider waits for payer to initiate recoupment – Example 6 or Example 7&8
PLB WO $+
PLB FB $- is possible if too little $$ to satisfy recoupment
3
X12 Content
Notes
ISA*
GS*
Example 1
ST*835
BPR*I*60
TRN*x*chk#1
CLP*pan1*22*100-*50-*0*15*pcn1
CLP*pan1*1*100*35*0*15*pcn1
CLP*pan2*1*200*75*0*15*pcn2
SE*
Payer
Payee
Reversal
Correction
unrelated claim
Example 2
ST*835
BPR*H*0
TRN*x*chk#2
CLP*pan1*22*100-*50-*0*15*pcn1
CLP*pan1*1*100*35*0*15*pcn1
CLP*pan3*1*50*10*0*15*pcn3
PLB*npi*20161231*FB*chk#2*5SE*
Payer
Payee
Reversal
Correction
unrelated claim
Need a forward balance
Example 3
ST*835
BPR*I*70
TRN*x*chk#3
CLP*pan4*1*200*75*0*15*pcn4
PLB*npi*20161231*FB*chk#2*5
SE*
Payer
Payee
unrelated claim
forward balance from chk#1
Example 4
ST*835
BPR*I*75
TRN*x*chk#4
CLP*pan1*22*100-*50-*0*15*pcn1
CLP*pan1*1*100*35*0*15*pcn1
CLP*pan5*1*200*75*0*15*pcn5
PLB*npi*20161231*WO*pan1 DOS*15SE
ST*835
BPR*I*75
TRN*x*chk#5
Payer
Payee
Reversal
Correction
unrelated claim
delay the recoupment
Example 5
X12 Content
CLP*pan6*1*200*75*0*15*pcn6
PLB*npi*20161231*72*provchk#*15-*WO*pan1
DOS*15
SE*
Notes
Payer
Payee
unrelated claim
provider sends refund of $15
Example 6
ST*835
BPR*I*60
TRN*x*chk#6
CLP*pan7*1*200*75*0*15*pcn7
PLB*npi*20161231*WO*pan1 DOS*15
SE*
Payer
Payee
unrelated claim
take the delayed recoupment
Example 7
ST*835
BPR*H*0
TRN*x*chk#7
CLP*pan8*1*50*10*0*15*pcn8
PLB*npi*20161231*WO*pan1 DOS*15*FB*chk#7*5SE
Payer
Payee
unrelated claim
take the delayed recoupment; need a forward balance
Example 8
ST*835
BPR*I*70
TRN*x*chk#8
CLP*pan9*1*200*75*0*15*pcn9
PLB*npi*20161231*FB*chk#7*5
SE*
Payer
Payee
unrelated claim
forward balance from chk#7