Overview of Electronic Secondary Claims (COB)

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Electronic Secondary Claims (COB) Overview-NextGen® PM Transaction Posting with Encounter Rate Billing Primary payers, such as Medicare, which are setup to split-bill an encounter rate on a UB claim to Medicare Part A with an alternate payer for carve-out services on a 1500 claim to Medicare Part B, may present some challenges with secondary claims. Secondary payers receiving fee-for-service on a 1500 claim will generally want to see the payments and adjustments from the primary payer documented on the secondary claim Additional documentation titled “EPM Encounter Rate Billing and Secondary Claims” has been created to guide you through the following: Process of posting transactions from a primary encounter rate payer creating a balanced electronic secondary claim for a fee-for-service secondary payer Process of posting transactions from a primary payment from Medicare Part B to the carve-out services to create a balanced secondary claim When to use the NextGen® Portal This information is available in the NextGen® Knowledge Exchange. NEXTGEN® Healthcare, Inc. EPMClaims © Copyright 2010 All Rights Reserved Confidential and Proprietary DO NOT COPY V5.6SP1 Sept2010 Page 24 of 29
Electronic Secondary Claims (COB) Overview-NextGen® PM Claim Edits & Billing - Reviewing Claim Production Status Report To prevent unbalanced secondary claims from creating, several claim edits are available: 254: COB edit: Paid amount and patient responsible amounts do not equal allowed amount 255: COB edit: All payments and adjustments do not equal billed amount 256: Value code 39a of required for secondary institutional claim o Only for client‟s sending 837I 261: Electronic COB claim requires adjudication date As with all claim edits, in order to prevent an encounter from producing a claim when the edit is fired, set the edit severity to „Required‟. If you set the claim edit severity to „Warning‟, you may correct the encounter and rebill before generating the next Secondary EDI file. Be sure to delete the previous claim generated. Otherwise two claims will be generated, one balanced and other unbalanced. COB edits will only fire if a Payer‟s Secondary Media Type is set to “Paper” and only when you are billing encounters. NEXTGEN® Healthcare, Inc. EPMClaims © Copyright 2010 All Rights Reserved Confidential and Proprietary DO NOT COPY V5.6SP1 Sept2010 Page 25 of 29
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Page 17 and 18: Continue that same process for each
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Overview of Electronic Secondary Claims (COB)

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