Post by peter@crystalpm on Jun 27, 2014 10:49:38 GMT -6
I've had several questions about this in the last few days and the information people are getting, they tell me, is inconsistent. So here is documentation on how to send a secondary electronic claim. 
I've set up a scenario in the test system that I hope is similar to a real life example that you may come across, but this is not a real patient, and not a real office, and I'm billing the DME and Medicaid out of order. In a real world claim it should be Dme Medicare as primary and Medicaid as secondary. The process is the same whichever payers you use.
My patient has medicaid and frames for DME. Here is my invoice with the items being assigned to insurance. Notice I already had to void the lenses because the billing code with quantity of 2 doubled the cost of the lenses, so I had to fix it.
Because its a DME claim there are a few special things we need to make sure are correct on the claim form. Open the claim form and make sure box17 reflects an "Ordering Physician" (code "DK") and box 24b reflects where the durable medical equipment will be used, presumably in the patient's home so (code "12"). My claim form will look like this and if we were sending a paper claim, this would be all we need to do.
But that is not all we have to do! They won't accept a paper claim, we need to send them an electronic file with the claim information. AND, since this is a secondary claim, they will only accept it if we can include information in the claim file that describes what the primary payer paid and what reasons they gave for what they did not pay. Ok, do you have your EOB handy? You'll need it.
Click the "Additional ANSI information" to open the windows that contain the information that will go into the ANSI file. These windows convert the information from the 1500 claim form and show us what is being sent in the electronic claim.
Right away we see that the insurance listed is DME, which is good, but it is the only insurance, which means that it is by default the primary insurance, which is bad. The patient has another medicaid insurance on their record and we want to pull that into this claim and make them primary. The first step to do this is to click on the "Add Another" tab, which will go find another insurance from the patient page and bring it in here.
It found the medicaid, but the order is reversed. To move medicaid to primary, press the "move left" (<) button next to the member ID field.
Much better! Now, Medicaid is primary, DME is seconday. We want to make sure that the file is setup correctly for sending to the seconday (DME), so go to the secondary tab and make sure that the "Send to this insurance" checkbox is selected.
And we see here that it is.
NOTE: Although it doesn't have anything to do with secondary billing, this is still a DME claim, so you should see that there is an "Ordering Physician" instead of "Rendering" as I show in my screen shots. If you have a "Rendering" and no "Ordering ..." then simply change the drop down box and choose "Ordering ..." for that provider. If you have both, delete the "Rendering".
ALSO NOTE: You may need to also explain to medicare why medicare is secondary, which is the drop down list at the bottom.
NOTE: if you need to send a corrected claim, the drop down under the providers, left of the "Continue to Claim" button is where you would specify that information.
Now that our insurance information looks good and our providers are all straightened out, we can continue to the claim information on Page 2 of the ANSI windows. Click the "Continue to Claim" button.
Slide the window to the right to see some hidden area where payment information goes.
From our EOB we fill in the amounts and reason codes.
Here is a description of what the numbers mean:
(1)Deductible Amount
(2)Coinsurance Amount
(3)Co-payment Amount
(4)The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(5)The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(6)The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(7)The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(8)The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(9)The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(10)The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(11)The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(12)The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(13)The date of death precedes the date of service.
(14)The date of birth follows the date of service.
(15)The authorization number is missing, invalid, or does not apply to the billed services or provider.
(16)Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(18)Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use with Group Code OA).
(19)This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
(20)This injury/illness is covered by the liability carrier.
(21)This injury/illness is the liability of the no-fault carrier.
(22)This care may be covered by another payer per coordination of benefits.
(23)The impact of prior payer(s) adjudication including payments and/or adjustments.
(24)Charges are covered under a capitation agreement/managed care plan.
(26)Expenses incurred prior to coverage.
(27)Expenses incurred after coverage terminated.
(29)The time limit for filing has expired.
(31)Patient cannot be identified as our insured.
(32)Our records indicate that this dependent is not an eligible dependent as defined.
(33)Insured has no dependent coverage.
(34)Insured has no coverage for newborns.
(35)Lifetime benefit maximum has been reached.
(38)Services not provided or authorized by designated (network/primary care) providers.
(39)Services denied at the time authorization/pre-certification was requested.
(40)Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(44)Prompt-pay discount.
(45)Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
(49)These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(50)These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(51)These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(53)Services by an immediate relative or a member of the same household are not covered.
(54)Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(55)Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(56)Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(58)Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(59)Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(60)Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
(61)Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(66)Blood Deductible.
(69)Day outlier amount.
(70)Cost outlier - Adjustment to compensate for additional costs.
(74)Indirect Medical Education Adjustment.
(75)Direct Medical Education Adjustment.
(76)Disproportionate Share Adjustment.
(78)Non-Covered days/Room charge adjustment.
(85)Patient Interest Adjustment (Use Only Group code PR)
(89)Professional fees removed from charges. Notes: Only use when the payment of interest is the responsibility of the patient.
(90)Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
(91)Dispensing fee adjustment.
(94)Processed in Excess of charges.
(95)Plan procedures not followed.
(96)Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(97)The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(100)Payment made to patient/insured/responsible party/employer.
(101)Predetermination: anticipated payment upon completion of services or claim adjudication.
(102)Major Medical Adjustment.
(103)Provider promotional discount (e.g., Senior citizen discount).
(104)Managed care withholding.
(105)Tax withholding.
(106)Patient payment option/election not in effect.
(107)The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(108)Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(109)Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. This change effective 11/1/2012: Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
(110)Billing date predates service date.
(111)Not covered unless the provider accepts assignment.
(112)Service not furnished directly to the patient and/or not documented.
(114)Procedure/product not approved by the Food and Drug Administration.
(115)Procedure postponed, canceled, or delayed.
(116)The advance indemnification notice signed by the patient did not comply with requirements.
(117)Transportation is only covered to the closest facility that can provide the necessary care.
(118)ESRD network support adjustment.
(119)Benefit maximum for this time period or occurrence has been reached.
(121)Indemnification adjustment - compensation for outstanding member responsibility.
(122)Psychiatric reduction.
(125)Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(128)Newborn's services are covered in the mother's Allowance.
(129)Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(130)Claim submission fee.
(131)Claim specific negotiated discount.
(132)Prearranged demonstration project adjustment.
(133)The disposition of the claim/service is pending further review. This change effective 1/1/2013: The disposition of the claim/service is pending further review. Use Group Code OA.
(134)Technical fees removed from charges.
(135)Interim bills cannot be processed.
(136)Failure to follow prior payer's coverage rules. (Use Group Code OA).
(137)Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
(138)Appeal procedures not followed or time limits not met.
(139)Contracted funding agreement - Subscriber is employed by the provider of services.
(140)Patient/Insured health identification number and name do not match.
(142)Monthly Medicaid patient liability amount.
(143)Portion of payment deferred.
(144)Incentive adjustment, e.g. preferred product/service.
(146)Diagnosis was invalid for the date(s) of service reported.
(147)Provider contracted/negotiated rate expired or not on file.
(148)Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(149)Lifetime benefit maximum has been reached for this service/benefit category.
(150)Payer deems the information submitted does not support this level of service.
(151)Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
(152)Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(153)Payer deems the information submitted does not support this dosage.
(154)Payer deems the information submitted does not support this day's supply.
(155)Patient refused the service/procedure.
(157)Service/procedure was provided as a result of an act of war.
(158)Service/procedure was provided outside of the United States.
(159)Service/procedure was provided as a result of terrorism.
(160)Injury/illness was the result of an activity that is a benefit exclusion.
(161)Provider performance bonus
(162)State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
(163)Attachment referenced on the claim was not received.
(164)Attachment referenced on the claim was not received in a timely fashion.
(165)Referral absent or exceeded.
(166)These services were submitted after this payers responsibility for processing claims under this plan ended.
(167)This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(168)Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
(169)Alternate benefit has been provided.
(170)Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(171)Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(172)Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(173)Service was not prescribed by a physician.
(174)Service was not prescribed prior to delivery.
(175)Prescription is incomplete.
(176)Prescription is not current.
(177)Patient has not met the required eligibility requirements.
(178)Patient has not met the required spend down requirements.
(179)Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(180)Patient has not met the required residency requirements.
(181)Procedure code was invalid on the date of service.
(182)Procedure modifier was invalid on the date of service.
(183)The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(184)The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(185)The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(186)Level of care change adjustment.
(187)Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
(188)This product/procedure is only covered when used according to FDA recommendations.
(189)'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
(190)Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
(191)Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)
(192)Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
(193)Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
(194)Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
(195)Refund issued to an erroneous priority payer for this claim/service.
(197)Precertification/authorization/notification absent.
(198)Precertification/authorization exceeded.
(199)Revenue code and Procedure code do not match.
(200)Expenses incurred during lapse in coverage
(201)Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR).
(202)Non-covered personal comfort or convenience services.
(203)Discontinued or reduced service.
(204)This service/equipment/drug is not covered under the patient’s current benefit plan
(205)Pharmacy discount card processing fee
(206)National Provider Identifier - missing.
(207)National Provider identifier - Invalid format
(208)National Provider Identifier - Not matched.
(209)Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
(210)Payment adjusted because pre-certification/authorization not received in a timely fashion
(211)National Drug Codes (NDC) not eligible for rebate, are not covered.
(212)Administrative surcharges are not covered
(213)Non-compliance with the physician self referral prohibition legislation or payer policy.
(214)Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
(215)Based on subrogation of a third party settlement
(216)Based on the findings of a review organization
(217)Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only)
(218)Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
(219)Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
(220)The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only)
(221)Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
(222)Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(223)Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
(224)Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
(225)Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
(226)Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(227)Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(228)Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
(229)Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer’s cost avoidance policy allows providers to bypass claim submission to a prior payer. Use Group Code PR.
(230)No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
(231)Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(232)Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
(233)Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
(234)This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(235)Sales Tax
(236)This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative.
(237)Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(238)Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR).
(239)Claim spans eligible and ineligible periods of coverage. Rebill separate claims (use Group Code OA). This change effective 11/1/2012: Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
(240)The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(241)Low Income Subsidy (LIS) Co-payment Amount
(242)Services not provided by network/primary care providers.
(243)Services not authorized by network/primary care providers.
I've set up a scenario in the test system that I hope is similar to a real life example that you may come across, but this is not a real patient, and not a real office, and I'm billing the DME and Medicaid out of order. In a real world claim it should be Dme Medicare as primary and Medicaid as secondary. The process is the same whichever payers you use.
My patient has medicaid and frames for DME. Here is my invoice with the items being assigned to insurance. Notice I already had to void the lenses because the billing code with quantity of 2 doubled the cost of the lenses, so I had to fix it.
Because its a DME claim there are a few special things we need to make sure are correct on the claim form. Open the claim form and make sure box17 reflects an "Ordering Physician" (code "DK") and box 24b reflects where the durable medical equipment will be used, presumably in the patient's home so (code "12"). My claim form will look like this and if we were sending a paper claim, this would be all we need to do.
But that is not all we have to do! They won't accept a paper claim, we need to send them an electronic file with the claim information. AND, since this is a secondary claim, they will only accept it if we can include information in the claim file that describes what the primary payer paid and what reasons they gave for what they did not pay. Ok, do you have your EOB handy? You'll need it.
Click the "Additional ANSI information" to open the windows that contain the information that will go into the ANSI file. These windows convert the information from the 1500 claim form and show us what is being sent in the electronic claim.
Right away we see that the insurance listed is DME, which is good, but it is the only insurance, which means that it is by default the primary insurance, which is bad. The patient has another medicaid insurance on their record and we want to pull that into this claim and make them primary. The first step to do this is to click on the "Add Another" tab, which will go find another insurance from the patient page and bring it in here.
It found the medicaid, but the order is reversed. To move medicaid to primary, press the "move left" (<) button next to the member ID field.
Much better! Now, Medicaid is primary, DME is seconday. We want to make sure that the file is setup correctly for sending to the seconday (DME), so go to the secondary tab and make sure that the "Send to this insurance" checkbox is selected.
And we see here that it is.
NOTE: Although it doesn't have anything to do with secondary billing, this is still a DME claim, so you should see that there is an "Ordering Physician" instead of "Rendering" as I show in my screen shots. If you have a "Rendering" and no "Ordering ..." then simply change the drop down box and choose "Ordering ..." for that provider. If you have both, delete the "Rendering".
ALSO NOTE: You may need to also explain to medicare why medicare is secondary, which is the drop down list at the bottom.
NOTE: if you need to send a corrected claim, the drop down under the providers, left of the "Continue to Claim" button is where you would specify that information.
Now that our insurance information looks good and our providers are all straightened out, we can continue to the claim information on Page 2 of the ANSI windows. Click the "Continue to Claim" button.
Slide the window to the right to see some hidden area where payment information goes.
From our EOB we fill in the amounts and reason codes.
Here is a description of what the numbers mean:
(1)Deductible Amount
(2)Coinsurance Amount
(3)Co-payment Amount
(4)The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(5)The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(6)The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(7)The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(8)The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(9)The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(10)The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(11)The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(12)The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(13)The date of death precedes the date of service.
(14)The date of birth follows the date of service.
(15)The authorization number is missing, invalid, or does not apply to the billed services or provider.
(16)Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(18)Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use with Group Code OA).
(19)This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
(20)This injury/illness is covered by the liability carrier.
(21)This injury/illness is the liability of the no-fault carrier.
(22)This care may be covered by another payer per coordination of benefits.
(23)The impact of prior payer(s) adjudication including payments and/or adjustments.
(24)Charges are covered under a capitation agreement/managed care plan.
(26)Expenses incurred prior to coverage.
(27)Expenses incurred after coverage terminated.
(29)The time limit for filing has expired.
(31)Patient cannot be identified as our insured.
(32)Our records indicate that this dependent is not an eligible dependent as defined.
(33)Insured has no dependent coverage.
(34)Insured has no coverage for newborns.
(35)Lifetime benefit maximum has been reached.
(38)Services not provided or authorized by designated (network/primary care) providers.
(39)Services denied at the time authorization/pre-certification was requested.
(40)Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(44)Prompt-pay discount.
(45)Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
(49)These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(50)These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(51)These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(53)Services by an immediate relative or a member of the same household are not covered.
(54)Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(55)Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(56)Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(58)Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(59)Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(60)Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
(61)Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(66)Blood Deductible.
(69)Day outlier amount.
(70)Cost outlier - Adjustment to compensate for additional costs.
(74)Indirect Medical Education Adjustment.
(75)Direct Medical Education Adjustment.
(76)Disproportionate Share Adjustment.
(78)Non-Covered days/Room charge adjustment.
(85)Patient Interest Adjustment (Use Only Group code PR)
(89)Professional fees removed from charges. Notes: Only use when the payment of interest is the responsibility of the patient.
(90)Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
(91)Dispensing fee adjustment.
(94)Processed in Excess of charges.
(95)Plan procedures not followed.
(96)Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(97)The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(100)Payment made to patient/insured/responsible party/employer.
(101)Predetermination: anticipated payment upon completion of services or claim adjudication.
(102)Major Medical Adjustment.
(103)Provider promotional discount (e.g., Senior citizen discount).
(104)Managed care withholding.
(105)Tax withholding.
(106)Patient payment option/election not in effect.
(107)The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(108)Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(109)Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. This change effective 11/1/2012: Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
(110)Billing date predates service date.
(111)Not covered unless the provider accepts assignment.
(112)Service not furnished directly to the patient and/or not documented.
(114)Procedure/product not approved by the Food and Drug Administration.
(115)Procedure postponed, canceled, or delayed.
(116)The advance indemnification notice signed by the patient did not comply with requirements.
(117)Transportation is only covered to the closest facility that can provide the necessary care.
(118)ESRD network support adjustment.
(119)Benefit maximum for this time period or occurrence has been reached.
(121)Indemnification adjustment - compensation for outstanding member responsibility.
(122)Psychiatric reduction.
(125)Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(128)Newborn's services are covered in the mother's Allowance.
(129)Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(130)Claim submission fee.
(131)Claim specific negotiated discount.
(132)Prearranged demonstration project adjustment.
(133)The disposition of the claim/service is pending further review. This change effective 1/1/2013: The disposition of the claim/service is pending further review. Use Group Code OA.
(134)Technical fees removed from charges.
(135)Interim bills cannot be processed.
(136)Failure to follow prior payer's coverage rules. (Use Group Code OA).
(137)Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
(138)Appeal procedures not followed or time limits not met.
(139)Contracted funding agreement - Subscriber is employed by the provider of services.
(140)Patient/Insured health identification number and name do not match.
(142)Monthly Medicaid patient liability amount.
(143)Portion of payment deferred.
(144)Incentive adjustment, e.g. preferred product/service.
(146)Diagnosis was invalid for the date(s) of service reported.
(147)Provider contracted/negotiated rate expired or not on file.
(148)Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(149)Lifetime benefit maximum has been reached for this service/benefit category.
(150)Payer deems the information submitted does not support this level of service.
(151)Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
(152)Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(153)Payer deems the information submitted does not support this dosage.
(154)Payer deems the information submitted does not support this day's supply.
(155)Patient refused the service/procedure.
(157)Service/procedure was provided as a result of an act of war.
(158)Service/procedure was provided outside of the United States.
(159)Service/procedure was provided as a result of terrorism.
(160)Injury/illness was the result of an activity that is a benefit exclusion.
(161)Provider performance bonus
(162)State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
(163)Attachment referenced on the claim was not received.
(164)Attachment referenced on the claim was not received in a timely fashion.
(165)Referral absent or exceeded.
(166)These services were submitted after this payers responsibility for processing claims under this plan ended.
(167)This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(168)Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
(169)Alternate benefit has been provided.
(170)Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(171)Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(172)Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(173)Service was not prescribed by a physician.
(174)Service was not prescribed prior to delivery.
(175)Prescription is incomplete.
(176)Prescription is not current.
(177)Patient has not met the required eligibility requirements.
(178)Patient has not met the required spend down requirements.
(179)Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(180)Patient has not met the required residency requirements.
(181)Procedure code was invalid on the date of service.
(182)Procedure modifier was invalid on the date of service.
(183)The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(184)The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(185)The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(186)Level of care change adjustment.
(187)Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
(188)This product/procedure is only covered when used according to FDA recommendations.
(189)'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
(190)Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
(191)Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)
(192)Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
(193)Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
(194)Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
(195)Refund issued to an erroneous priority payer for this claim/service.
(197)Precertification/authorization/notification absent.
(198)Precertification/authorization exceeded.
(199)Revenue code and Procedure code do not match.
(200)Expenses incurred during lapse in coverage
(201)Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR).
(202)Non-covered personal comfort or convenience services.
(203)Discontinued or reduced service.
(204)This service/equipment/drug is not covered under the patient’s current benefit plan
(205)Pharmacy discount card processing fee
(206)National Provider Identifier - missing.
(207)National Provider identifier - Invalid format
(208)National Provider Identifier - Not matched.
(209)Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
(210)Payment adjusted because pre-certification/authorization not received in a timely fashion
(211)National Drug Codes (NDC) not eligible for rebate, are not covered.
(212)Administrative surcharges are not covered
(213)Non-compliance with the physician self referral prohibition legislation or payer policy.
(214)Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
(215)Based on subrogation of a third party settlement
(216)Based on the findings of a review organization
(217)Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only)
(218)Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
(219)Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
(220)The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only)
(221)Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
(222)Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(223)Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
(224)Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
(225)Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
(226)Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(227)Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(228)Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
(229)Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer’s cost avoidance policy allows providers to bypass claim submission to a prior payer. Use Group Code PR.
(230)No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
(231)Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(232)Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
(233)Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
(234)This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(235)Sales Tax
(236)This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative.
(237)Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
(238)Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR).
(239)Claim spans eligible and ineligible periods of coverage. Rebill separate claims (use Group Code OA). This change effective 11/1/2012: Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
(240)The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(241)Low Income Subsidy (LIS) Co-payment Amount
(242)Services not provided by network/primary care providers.
(243)Services not authorized by network/primary care providers.
