Coordination of Benefits Agreement (COBA) Medigap Claim-

80.7 - Coordination of Benefits Agreement (COBA) Medigap Claim- Based Crossover Process (Rev. 4009, Issued: 03-23-18, Effective: 04-23-18, Implementation: 04-23-18) Effective with claims submitted to Medicare on October 1, 2007, and after, participating physicians and suppliers will be expected to include a 5 byte COBA identifier (range 55000---55999) on incoming crossover claims for purposes of triggering claim-based Medigap crossovers. Additionally, effective with October 1, 2007, claim-based Medigap crossovers will occur exclusively through the BCRC in the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12-N 837 professional claim format (current version) and National Council for Prescription Drug Programs (NCPDP) claim format. A. Changes to A/B MAC or DME MAC Up-Front Screening Processes for COBA Claim-based Medigap Crossovers Effective with claims that the A/B MACs (B) and DME MACs will cable to CWF on October 1, 2007, their internal processes for screening claims for Medigap claim-based crossovers shall be modified to accommodate the new Medigap claim-based COBA crossover process. The affected A/B MACs (B) and DME MACs’ processes for screening claims for Medigap claim-based crossovers shall now feature a syntactic editing of the incoming COBA claim-based Medigap ID to ensure that the identifier begins with a “5” and contains 5 numeric digits. In addition, for incoming 837 professional and NCPDP claims, A/B MACs (B) and DME MACs shall ensure that the Medigap claim-based COBA ID is entered within the appropriately designated field, loop, or segment of the incoming Medicare claim. If the claim fails the syntactic verification, the A/B MAC (B) or MAC shall not copy the identifier from the incoming claim and populate it within field 34 (“Crossover ID”) of the HUBC or HUDC claim transaction that is sent to the CWF for verification and validation. Instead, the A/B MAC (B) or DME MACs shall continue to follow its pre-existing processes for notifying the provider via the ERA or other remittance advice and the beneficiary via the MSN that the information reported did not result in the claim being crossed over. The affected A/B MACs (B) or DME MACs’ screening processes for Medigap claim-based crossovers shall also continue to include verification that the provider participates with Medicare and that the beneficiary has assigned benefits to the provider. If the provider-populated value for the Medigap claim-based ID passes the A/B MAC (B) or DME MAC’s syntactic editing process, the affected A/B MAC or DME MACs’ systems shall copy the Medigap claim-based COBA ID value from the incoming claim to field 34 of the HUBC or HUDC claims transactions that are sent to CWF for verification and validation. The A/B MACs (B) and DME MACs shall populate the identifier in field 34 right-justified and prefixed with five zeroes. B. CWF Validation of Values within Field 34 of the HUBC and HUDC Transactions Upon receipt of HUBC and HUDC claims that contain a value within field 34 (“Crossover ID”), the CWF shall read the value that is present within the field for purposes of conducting a validity check. The CWF shall accept the following values as valid within field 34: a value within the range of 0000055000 to 0000059999, or spaces. If the A/B MAC (B) or DME MAC has sent an inappropriate value in field 34 of the HUBC and HUDC claims transaction, CWF shall return an alert code 7704 on the “01” disposition response via the claim-based alert trailer 21. For customer service purposes, the CWF maintainer shall create a new crossover disposition indicator “Z” to accommodate the scenario of the A/B MAC (B) or DME MAC sending an incorrect value within field 34 of the HUBC and HUDC transaction. (See §80.5 of this chapter for more information regarding this crossover disposition indicator.) At the point that CWF returns an alert code 7704 to the affected A/B MAC (B) or DME MAC, it shall take the following actions with respect to the claim: 1. Mark the claim with crossover disposition indicator “Z” (“invalid Medigap claim- based crossover ID included on the claim”); and 2. Display the indicator, together with the invalid COBA ID value from field 34, in association with the claim on the appropriate HIMR detailed history screen in the “claim- based crossover” segment. See Pub.100-04 chapter 28, §70.6.4 for an explanation of A/B MAC or DME MAC processes following receipt of a CWF alert code 7704 via a 21 trailer. C. CWF Processing for COBA Claim-based Medigap Crossovers Following receipt of an HUBC and HUDC claims transaction that contains a valid value within field 34 (a value within the range of 0000055000 to 0000059999 or spaces), CWF shall check for the presence of a BOI auxiliary record for the purpose of triggering eligibility file-based crossovers. CWF shall then read the COIF to determine the claims selection criteria for any eligibility file-based trading partners (all other COBA IDs) as well as for the Medigap claim-based insurer (range 0000055000 to 0000059999). If the HUBC or HUDC claim contains a valid COBA Medigap claim-based ID within field 34 but the valid ID cannot be found on the COIF, the CWF shall post the valid COBA Medigap claim-based ID without an accompanying crossover disposition indicator in association with the claim within the “claim-based crossover” segment of the appropriate HIMR claim detailed history screen. If the claim meets the COBA trading partner’s selection criteria, as per the COIF, and none of the other scenarios presented below applies, CWF shall return a Beneficiary Other Insurance (BOI) reply trailer (29) to the A/B MAC (Part B) or DME MAC for purposes of having the A/B MAC (B) or DME MAC trigger a crossover to the BCRC. Duplicate Check The CWF shall perform a duplicate check to determine if the beneficiary is identified for crossover to a Medigap eligibility file-based insurer (COBA ID 30000-54999) and to a Medigap claim-based insurer (COBA ID 0000055000-0000059999). If CWF determines that the beneficiary is identified for crossover to both a “production” Medigap eligibility file-based insurer (COBA ID range=30000 to 54999) and a Medigap claim-based Medigap insurer (COBA ID range=0000055000 to 0000059999), it shall suppress the BOI reply trailer (29) for the claim-based Medigap insurer (COBA ID range= 0000055000 to 0000059999). Crossover Disposition Indicator “AA” Effective with October 1, 2007, the CWF maintainer created a new crossover disposition indicator “AA” to accommodate the CWF duplicate check, where it has determined that the beneficiary’s claim is eligible for crossover to both a “production” Medigap eligibility file-based insurer and a Medigap claim-based crossover insurer. After CWF has determined that beneficiary has already been identified for Medigap eligibility file-based crossover, it shall take the following actions with respect to the claim: 1. Mark the associated claim with indicator “AA” (“beneficiary identified on Medigap insurer eligibility file; duplicate Medigap claim-based crossover voided); and 2. Display this indicator, together with the affected claim-based Medigap COBA ID, in association with the claim on the appropriate HIMR detailed history screen in the “claim-based crossover” segment. D. BOI Reply Trailer (29) Process If CWF determines that the claim meets the trading partner’s claims selection criteria, it shall select the claim and return a BOI reply trailer 29 for the claim to the affected A/B MAC (B) or DME MAC. The CWF shall display the appropriate crossover disposition indicator for the claim-based crossover claim within the “claim-based crossover” segment of the HIMR claim detailed history screens. As with the COBA eligibility file-based crossover process (see §80.4 of this chapter for more details regarding this process), CWF shall display the COBA ID and accompanying crossover disposition indicator on claim detailed history screens, with the exception of circumstances where the valid ID cannot be located on the COIF, as discussed above, or the Medigap claim-based insurer is in “test” mode with the BCRC. In these situations, only the COBA Medigap claim-based ID shall be displayed. Modification of the CWF Sort Routine For Multiple COBA IDs and Accompanying A/B MAC or DME MAC Actions Following Receipt of the BOI Reply Trailer (29) In light of the new COBA Medigap claim-based crossover process, the CWF sort routine for COBA IDs to be returned via the BOI reply 29 trailer shall be modified as follows: Medigap eligibility file-based (30000-54999), Medigap claim-based (55000-59999), supplemental (00001-29999), TRICARE for Life (60000-69999), Other insurer (80000- 89999), and Medicaid (70000-79999). (NOTE: This information is also being updated in §80.4 of this chapter) Upon receipt of the BOI reply trailer (29), the affected A/B MAC (B) or DME MAC shall continue to utilize information from this source to populate the beneficiary’s MSN and provider ERA or other remittance advice in production in accordance with the existing guidance that appears in §80.4 of this chapter.