CMS is seeking guidance from the ASC X12 to use the 5010A1 version of the ASC X12 837 professional TR3 to process Medicare subrogation claims.

In accordance with 42 U.S.C. § 1395u(b)(6)(B); and 42 C.F.R. 424.66, Medicare is required to pay Part B claims under an Indirect Payment Procedure (IPP) to qualifying entities under qualifying conditions. In this IPP, the entity seeking payment has provided a complementary health benefit plan to a Medicare beneficiary and has paid a Medicare provider for the services the beneficiary has received. Medicare is required to reimburse the IPP (when certain qualifications are met). Currently Medicare is processing these claims via paper. While the current volume of paper IPP claims is manageable, we anticipate more complementary health plans to become registered to submit IPP claims, and the volume of IPP claims to increase significantly over time. Therefore, CMS would like to establish a process for submitting these claims electronically as soon as possible.

Pertinent reference from the X222A1:

Section 1.4.1.5 describes Medicaid Subrogation specifically with no other business application.

The BHT06 note reads:

31 Subrogation Demand

The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction.

The AMT02 of the 2320 AMT - Coordination of Benefits (COB) Payer Paid Amount description reads:

"When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid."

The CLM01 description reads in part:

"When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies."

By the way, there is a typo in this description. It should read "See Section 1.4.1.5"

It seems to me these notes/descriptions make it clear that this usage is for Medicaid only. The only notes that appear to leave it open for any subrogation is the 2010AC Pay to Plan Name. The Situational Rule reads "Required when willing trading partners agree to use this implementation for their subrogation payment requests."

I don't see a work around that would allow Medicare (or any other non Medicaid payer) to use the current 5010 TR3's for this use. Anyone see it differently?

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