Submitting Electronic Claims when Other Health Insurance (OHI) is Primary
Secondary and tertiary West Region claims can be submitted electronically
through a clearinghouse, direct submission or
www.triwest.com.
The required information from the other health insurance (OHI) explanation of
benefits (EOB) must be included in the claim submission.
Electronic submission of secondary or
tertiary claims Web claims requires the primary payer allowed amount, paid
amount, and the OHI Payment Reason code.
EDI (837P or 837I) claims transactions
In order to assure proper adjudication of
claims containing primary payer involvement, it is strongly recommended that EDI
claims include the primary payer amount allowed, paid amount, and reason if no
prior payment is made on claims submitted. TRICARE follows the ASC X12 837
implementation guides for the needed elements to process.
The following outline provides the basic
elements of the 837 needed for secondary and tertiary claims processing:
- Other Subscriber Information (SBR) – The 2320 loop is required when reporting other insurance, prior or
otherwise. The multiple instances of SBRs breakdown multiple payers and
the claim adjudication decisions.
- AMT Prior Payer Paid - The 837 implementation guide requires this element if claim
adjudicated by prior payer.
- AMT - Allowed Amount – Allowed amounts can be provided at the AMT. However, if the AMT
cannot be reported, the Claim Level Adjustments (CAS) segment is necessary
to adjudicate.
- OI – Other Insurance Coverage Information – Required if 2320 loop is present.
To submit line
level OHI information, refer to the WPS 837 Companion Guide which can be found
in the Your EDI Connection area of
www.triwest.com/provider.
Note: TriWest pays claims
with OHI line-by-line. That means that if the other carrier pays on some lines
and not others, TriWest will consider each service on its own merit. The
TRICARE EOBs show the beneficiary responsibility. If it is ‘0’, the beneficiary
cannot be billed. (See Figure 1 for an example of a two line claim with OHI.) The beneficiary has no out-of-pocket
expenses.
Figure 1
Billed Amount
|
OHI Allowable Amount
|
OHI Paid
|
OHI Beneficiary Liability
|
TRICARE Allowable Amount
|
TRICARE Paid
|
Line 1 - $224
|
$200
|
$176
|
$24
|
$100
|
$24
|
Line 2 - $130
|
$97
|
$68
|
$29
|
$130
|
$29
|
Total - $354
|
$297
|
$244
|
$53
|
$230
|
$53
|
Published Date:
08/22/2008
