Utility/Insurance

 

 

 

Include Payment:        Enter Y, print payment applied to the charges on the CMS 1500 form Box 29.

 

 

/Charges/Charge

 

Post charges as usual.

 

NOTE 

 

In regard to PRIMARY PAYER LINE ADJUDICATION INFORMATION:

 

• When the primary insurance has attached to it a pay plan pointing to a fee schedule, that pay plan’s Approved amount is submitted electronically to Medicare. 

 

• When the primary insurance does not have an attached pay plan, the submitted Approved amount will equal the charge amount.

 

• Should you want to send Medicare their approved amount by attaching the Medicare Pay Plan to the primary insurance and that Medicare Pay Plan has an Alt Charge not equal to the Charge, the primary insurance will be billed the Alt Charge amount.  Thus, you may want to create an MSP Pay Plan where the Alt and Global amounts are the same.

 

 

PRIMARY GROUP POLICY NUMBER                                                      Loop 2320 SBR03

Where /New Patient/Insurance <Primary/Secondary (P/S/X)>=P

/New Patient/Insurance <Group No.>

 

PRIMARY INSURANCE PLAN NAME                                                      Loop 2320 SBR04

Where /New Patient/Insurance <Primary/Secondary(P/S/X)>=P

/New Patient/Insurance <Claim No.>

 

ANSI File Example:    SBR*P*01*GROUP#*BLUECROSSOFCA*SP****BL~

 

 

PRIMARY PAYER ALLOWED AMOUNT (TOTAL CLAIM)                              Loop 2320 AMT*B6 02

$715 is the total amount of the charges sent in this transmission for this patient (th_charge total)

 

ANSI File Example:    AMT*B6*715~

 

 

PRIMARY PAID AMOUNT (TOTAL CLAIM)                                          Loop 2320 AMT*D 02

$50 is the total amount of the payments made against the charges this transmission for this patient (th_payment total)

 

NOTE: Total payments, can include patient payments as well as primary insurer payments.

 

ANSI File Example:    AMT*D*50~

 

PRIMARY PLAN INSURED COMPLETE NAME

            Last Name                                                                                            Loop 2330A NM103

            First Name                                                                                            Loop 2330A NM104

            Middle Name                                                                                        Loop 2330A NM105

 

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=P and:

/New Patient/Insurance <Relation to Insured> = 1

/New Patient <Name (Last, First Init.)>

/New Patient/Insurance <Relation to Insured> = 2, 3, 4

/New Patient/Insurance <Insured’s Name>

 

NOTE: /New Patient/Insurance <Insured’s Name> name format MUST BE: LASTNAME, FIRSTNAME INITIAL   For example:    SMITH, JOHN D.

           

ANSI File Example:  NM1*IL*1*LASTNAME*FIRSTNAME*M***MI*INSSUBSCRIBER#~

 

 

PRIMARY PLAN INSURED ADDRESS

            Address                                                                                                Loop 2330A N301

            City                                                                                                       Loop 2330A N401

            State                                                                                                      Loop 2330A N402

            Zip Code                                                                                               Loop 2330A N403

 

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=P and:

/New Patient/Insurance <Relation to Insured> = 1

/New Patient <Address>, <Zip Code>, <City>, <State>

/New Patient/Insurance <Relation to Insured> = 2, 3, 4

/New Patient/Insurance Insured’s <Address>, <Zip Code>, <City>, <State>

 

ANSI File Example:    N3*INSURED’S ADDRESS~

                                    N4*CITY*STATE*ZIPCODE~

 

PRIMARY PAYER ORGANIZATION NAME                                                        Loop 2330B NM103

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=P

Corresponding <Insurance Co.> /Utility/Insurance <Name>

 

PRIMARY PAYER IDENTIFICATION NUMBER                                                Loop 2330B NM109

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=P

/New Patient/Insurance <Subscriber No.>

 

ANSI File Example:    NM1*PR*2*PRIMARYINSURANCECONAME*****PI*INSSUBSCRIBER#~

 

PRIMARY PAYER LINE ADJUDICATION INFORMATION

 

            Full Payment Amount                                                                         Loop 2400 CN1*09 02

 

There will be a CN1 segment for each charge in this transmission. It is the th_approved_amount at the time the charge was originally posted.

 

ANSI File Example:    CN1*09*155~

CN1*09*100~

CN1*09*80~

CN1*09*150~

CN1*09*230~

 

Allowed Amount                                                                                 Loop 2400 AMT*AAE 02

 

Each AMT*AAE will contain the individual charge amounts in this transmission The total of $715 is the total amount of the charges sent in this transmission for this patient (th_charge total) and must equal amount in Loop 2320 AMT*B6 02 PRIMARY PAYER ALLOWED AMOUNT

 

ANSI File Example:    AMT*AAE*155~

AMT*AAE*100~

AMT*AAE*80~

AMT*AAE*150~

AMT*AAE*230~

           

Identification Number                                                                        Loop 2430 SVD01

 

Must equal ID number in Loop 2330B NM109 PRIMARY PAYER

IDENTIFICATION NUMBER

 

            Paid Amount                                                                                       Loop 2430 SVD02

 

There will be a SVD segment for each charge in this transmission. The total of the amounts on these lines will be the same as >Loop 2320 AMT*D 02 PRIMARY PAID AMOUNT (TOTAL CLAIM)amount (in this case, $50) The payment amount for each SVD is the total amount of the payments made against the charge this transmission for this patient (th_payment total).

 

NOTE: Total payments, not just made by the primary payer necessarily

 

ANSI File Example:    SVD*INSSUBSCRIBER#*10.95*HC:99214**1~

                                    SVD*INSSUBSCRIBER#*6.93*HC:99100**1~

                                    SVD*INSSUBSCRIBER#*5.84*HC:81000**1~

                                    SVD*INSSUBSCRIBER#*10.95*HC:75720**1~

                                    SVD*INSSUBSCRIBER#*15.33*HC:76100**1~

               

Adjudication Date                                                                               Loop 2430 DTP03

 

There will be a DTP*573 for each charge because the payment dates do not have to be the same for all charges in this transmission. The date is taken from th_payment_date and doesn’t have to be only for the primary payer’s payment.  Format for the date is CCYYMMDD.

 

ANSI File Example:    DTP*573*D8*20040522~

 

 

MEDICARE PAYER NAME                                                                                    Loop 2010BB NM103

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=S

Corresponding <Insurance Co.> /Utility/Insurance <Name>

 

MEDICARE PAYER IDENTIFICATION                                                    Loop 2010BB NM109

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=S

/New Patient/Insurance <Subscriber No.>

 

ANSI File Example:    NM1*PR*2*MEDICAREINSURANCECONAME*****PI*INSSUBSCRIBER#~

 

MEDICARE INSURED HEALTH INSURANCE CLAIM NUMBER                    Loop 2010BA NM109

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=S

/New Patient/Insurance <Subscriber No.>

 

MEDICARE INSURED COMPLETE NAME

            Last Name                                                                                            Loop 2010BA NM103

            First Name                                                                                            Loop 2010BA NM104

Middle Name                                                                                        Loop 2010BA NM105

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=S

And <Relation to Insured>=1 (only option for Medicare claims)

/New Patient <Name (Last, First Init.)>

 

ANSI File Example:   NM1*IL*1*LASTNAME*FIRSTNAME*M***MI*INSSUBSCRIBER#~

MEDICARE INSURED ADDRESS

            Address                                                                                                Loop 2010BA N301

            City                                                                                                      Loop 2010BA N401

            State                                                                                                     Loop 2010BA N402

            Zip Code                                                                                               Loop 2010BA N403

Where  /New Patient/Insurance <Primary/Secondary (P/S/X)>=S

And <Relation to Insured>=1 (only option for Medicare claims)

/New Patient <Address>, <Zip Code>, <City>, <State>

 

ANSI File Example:    N3*INSURED’S ADDRESS~

                                    N4*CITY*STATE*ZIPCODE~