Utilizing X12N 837 for MSP Claims
Effective October 16, 2002,
Part B physicians and suppliers must submit all electronic Medicare
Secondary Payer (MSP) claims data using the ANSI X12N 837 (version
4010), unless physicians and suppliers request a one-year extension
to comply with HIPAA version 4010 under the provisions of the Administrative
Simplification Compliance Act. Currently, there are fields to identify
the other payer's allowed and paid amount on the 837; however, there
is no field on the 837 to specifically identify the Obligated to Accept
as Payment in Full (OTAF) amount. The OTAF amount is a payment (which
is less than your charges) that you are obligated to accept or agreed
to accept as payment in full satisfaction of the patient's payment
obligation. On most claims, the OTAF amount is greater than the amount
the primary payer actually paid on the claim. The Medicare program
uses the OTAF amount(s) when calculating its secondary liability on
such claims when services are paid on other than a reasonable charge
basis.
When you migrate to the X12N
4010 837, you must use the line level contract information (CN1)
segment to report the OTAF. Report the OTAF in CN102 (Contract Amount)
with a qualifier of "09" (Other) in CN101. If MSP data is received
at the claim level, report the OTAF in 2300 CN102. If MSP data is
received at the line level, report the OTAF in 2400 CN102. The X12N
4010 837 Professional Implementation Guide allows for claim
level OTAF reporting using the CN1 segment as described above, as
well as line level reporting using the line level CN1 segment. Furnish
line level primary payer data, including the OTAF amount, when available.
The chart below applies to
all providers. However, if you are a Minnesota provider, it only
applies to you after the Multi-Carrier System (MCS) conversion is
completed on November 1, 2002. This information also applies to
Minnesota providers if they are testing in MCS prior to November
1.
The chart below identifies
the segments and data elements that you must use to report: (1)
the submitted charges, (2) the primary payer paid amount, (3) the
primary payer allowed amount, and (4) the OTAF amount at the claim
and the service line levels.
| 837/3051 | NSF | 837 v 4010 | Comments | |
| Claim Total Submitted Charge | 2-130-CLM02 | XA0-12 | 2300 CLM02 | Must be equal to the sum of the lines. If the lines don't equal, return the claim to the physician or supplier. |
| Claim Primary Payer Paid Amount | 2-300-AMT02 AMT01 = D |
DA1-14 | 2320 AMT02 AMT01 = D |
Must be equal to the sum of the lines if the lines are available. If the lines don't equal, return the claim to the physician or supplier. |
| Claim Primary Payer Allowed Amount | 2-300-AMT02 AMT01= B6 |
DA1-11 | 2320 AMT02 AMT01 = B6 |
Must be equal to the sum of the lines if the lines are available. If the lines don't equal, return the claim to the physician or supplier. |
| Claim OTAF Amount | 2300 CN102 CN101=09, if 2400 CN101=09 is not available |
Must be equal to the sum of the lines. If the lines don't equal, return the claim to the physician or supplier. The claim level CN1 should be used only when the service line CN1 is not available. | ||
| Line Submitted Charge | 2-370-SV102 | FA0-13 | 2400 SV102 | None |
| Line Primary Payer Paid Amount | 2-475-AMT AMT01 = D |
FA0-35 | 2430 SVD02 | None |
| Line Primary Payer Allowed Amount | 2-475-AMT02 AMT01= B6 |
FB0-06 | 2400 AMT02 AMT01 = AAE |
If there is no value in the Allowed Amount field, use the value in the Approved Amount field. |
| Line OTAF | 2-475-AMT02 AMT01=CT |
FA0-48 | 2400 CN102 CN101 = 09 |
None |
Page Last Updated: Tuesday, 04-Dec-2007 13:19:18 CST
