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 Post subject: Secondary Claim Denials
PostPosted: Sun Nov 19, 2017 10:51 am 
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Joined: Fri Mar 11, 2011 6:59 pm
Posts: 245
Carefirst BC BS denied a number of our secondary claims, saying:

Adjustment reason code (loop 2430, CAS02, CAS05, CAS08, CAS11, CAS14, CAS17) must equal 253 (Sequest
ration - reduction in federal payment) when claim filing indicator code (loop 2320, SBR0
9) equals MA or MB and service line paid amount (loop 2430, SVD02) is greater than 0.49.
----------------------------------------------------------------------------------------

We posted all of the primary Medicare payments via ERA through RM. So, not sure if the IG is not set correctly since there are technically 2 different adjustment amounts from Medicare (contractual adjustments and sequestration adjustments).

Is this something can be fixed?

Thanks,
Steve

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Steven Zats
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PostPosted: Sun Nov 19, 2017 6:56 pm 
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Joined: Wed Apr 04, 2007 10:11 pm
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Location: Springfield, MO
Are both of those setup as insurance adjustment type codes in Medisoft?

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Gavin Walker
Walker Tek Solutions, LLC
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PostPosted: Mon Nov 20, 2017 11:30 am 
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Yes...And I just did a test secondary claim and it appears they are placing an adjustment reason code 237 for the sequestration amount and that is actually what is reported by Medicare on the EOB. See below. My guess is the IGuide is correct and Carefirst's denial is in error since Medicare is now and has been sending the CO-237 all along for the sequestration....and previously Carefirst had no problem with this being listed.



SV1*HC:97140:GP:59:::MANUAL THERAPY TECHNIQUES EG, MOBILIZAT*40*UN*1***1
DTP*472*D8*20171017
REF*6R*254306
SVD*12202*19.58*HC:97140:GP:59**1
CAS*CO*253*.4**59*8.69**45*5.64**237*0.69
CAS*PR*2*5
DTP*573*D8*20171101
AMT*EAF*5

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Steven Zats
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PostPosted: Mon Nov 20, 2017 1:51 pm 
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OK...got an answer about this. Medicare did list the sequestration amount as 253 but also listed a legislative adjustment (CO 237) and it appears Medicare has always had these 2 separate adjustments (one for CO253 for sequestration and one for CO237 for legislative).

BUT per Availity there is a payer specific edit and they consider the legislative adjustment to be sequestration (which it is) and they want to see 253, not 237.

So I guess I just have to send secondary claims to this payer on paper, right? Or can anything be done to create an IGuide just for this payer so if it says CO-237 it changes to CO-253?

Steve

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Steven Zats
Medical Billing Professionals


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PostPosted: Tue Nov 21, 2017 9:17 am 
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Location: Springfield, MO
It seems the secondary insurance is wrong and needs to allow for CO237 also. The only thing I can figure is to manually adjust CO237 so that it is not applied and then manually add the amount to the CO235 to make it one combined adjustment amount.


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PostPosted: Tue Nov 21, 2017 12:34 pm 
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Easier to just do the claims on paper and print out the primary EOBs. But thanks!

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Steven Zats
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PostPosted: Wed Nov 22, 2017 9:33 am 
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Location: Springfield, MO
Or that.. Medisoft v22 is supposed to have a feature that will allow you to print the EOB for just one patient to make it easy to attach to a secondary paper claim.


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PostPosted: Wed Nov 22, 2017 11:55 am 
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I am able to do that now. We use Change Healthcare for receiving ERAs and we can print for just one patient.

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Steven Zats
Medical Billing Professionals


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