Section title: Requests for Interpretation
835 Secondary Payment (OA23) Clarifications

There are some areas we’d like to see clarifications for a Medicaid secondary or tertiary payer.

  1. Please confirm this is when we’ve already processed a claim to payment and then get an exact duplicate of the submission vs. if the biller sends duplicate primary payer information (payments/claim adjustment reason codes). 
  2. Will you please help us understand your expectations in relation to PI, PR, CO, etc.? If we need to split the solution to account for PI different from PR/CO, this will add longer development and testing phases. We’re happy to do it, but we need to understand how the expectations are different.
  3. We’ve coded our system to combine prior payer payments and adjustments into OA23 values. We compare our allowed amount to the amount paid by primary payers to determine if/how much of the remaining member cost share we might pay. When the claim is allowed by Medicaid, we either provide payment or claim adjustment reason codes on the remaining member cost share.
RFI Response

RFI 2143 outlines the expected COB reporting for multiple scenarios based on code definitions (CARC, CAGC) and TR3 guide’s front matter regarding reporting COB. The TR3 and RFI 2143 explain how to report the accurate OA23 and other CAGC/CARC combinations as needed in each scenario. 

The 5010 835 TR3 defines what is included in the OA23: “From the perspective of the secondary payer, the "impact" of the primary payer's adjudication is a reduction in the payment amount. This "impact" may be up to the actual amount of the primary payment(s) plus contractual adjustment(s).”  The term “impact” in that description and within section of the 835 TR3 is to be used to identify the payments and contractual reductions that have already been posted to the AR by the provider. This even applies when the secondary payer doesn’t take into account what a prior payer actually adjudicated. It isn’t about the payer or the payer’s system or processes or contracts or business - it is about the provider’s AR system, automation, and posting.

This must be followed to report an accurate OA23 and prevent the provider from re-posting dollars they already posted from the priority payer’s remittance.   

  1. A duplicate claim is in the scenarios of when COB would not apply. It is up to the payer to determine if a claim is a duplicate claim.
  2. The OA23, impact of prior payer’s adjudication, includes prior payments and contractual adjustments based on the full coding CAGC, CARC, and RARC. The CAGC reports who was assigned responsibility for adjusted dollars in the prior payer’s adjudication. Without the CAGC a subsequent payer would not know if the dollars adjusted were assigned to a contractual adjustment (CO), assigned to patient responsibility (PR), or the dollars were not assigned due to no contract between the payer and provider (PI). 
  3. The expectations are the same for secondary, tertiary, and any subsequent priority payer positions.