In the HIX process there is a need to receive the amount that was applied to deductible, copay, and coinsurance from providers and how the government subsidy amounts are impacted. Is there guidance from the 837 worgroup on how this information is communicated in the 837 at the exchange level?
Additional Supporting Information Supplied by the submitter
This is a Delegation arrangement where another third party process’s claims on behalf of a Qualified Health Plan (QHP) issuer and the third party sends adjudication results to the QHP. The information being sent is critical for tracking and remediation with the government. In the new world of exchanges and government subsidies, there is more information that will be needed for accounting i.e. (the EHB indicator (essential health benefit) and/or gov't dollar amounts) and it is cumbersome to do it in a sidecar file. Examples of additional data needed:
Govt Deductible - Amount applied towards Govt Deductible
Govt Coinsurance - Amount applied towards Govt Out-of-pocket
Govt Co-pay - Amount applied towards Govt Out-of-pocket
Member cost share level
Essential Health Benefits indicator (Y/N)
The reporting of claims already adjudicated is accommodated by the Post Adjudicated Claims Data Reporting (PACDR) TR3s, 837 Institutional X299 and 837 Professional X298. The Health Care Claim TR3s, 837 Institutional X223A2 and 837 Professional X222A1, do not accommodate reporting adjudication information except for secondary or subsequent claims, prior adjudication information is accommodated.
The PACDR TR3s convey deductible, coinsurance and co-payment amounts in the CAS segment. The codes used in the CAS segment, Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) are external to the ASC X12 standard and any additional code needs to differentiate e.g. types of deductible, would be submitted to the appropriate code maintenance committee.
There is currently no essential health benefits indicator and no member cost sharing level in the PACDR TR3s. Please submit a request with detailed business requirements for the essential health benefits indicator and member cost sharing level to modify a future version of the Post Adjudicated Claims Data Reporting (PACDR) TR3s, 837 Institutional and 837 Professional, through the online TR3 Maintenance Request tool at: http://changerequest.x12.org/