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Secondary Claim Denials

Posted: Sun Nov 19, 2017 10:51 am
by mbpros
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.
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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

Re: Secondary Claim Denials

Posted: Sun Nov 19, 2017 6:56 pm
by Gavin Walker
Are both of those setup as insurance adjustment type codes in Medisoft?

Re: Secondary Claim Denials

Posted: Mon Nov 20, 2017 11:30 am
by mbpros
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

Re: Secondary Claim Denials

Posted: Mon Nov 20, 2017 1:51 pm
by mbpros
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

Re: Secondary Claim Denials

Posted: Tue Nov 21, 2017 9:17 am
by Gavin Walker
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.

Re: Secondary Claim Denials

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

Re: Secondary Claim Denials

Posted: Wed Nov 22, 2017 9:33 am
by Gavin Walker
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.

Re: Secondary Claim Denials

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