MMIS POSC Job Aid: Professional Claim Submission to MassHealth with Coordination of Benefits Information This job aid reviews the process of submitting an electronic professional claim in the Provider Online Service Center (POSC). For specific billing information, providers should reference the relevant billing guides, available at www.mass.gov/masshealthpubs (click the Provider Library to access a specific guide). The instructions contained in this job aid describe the steps providers should follow to report coordination of benefits (COB) information on their Professional direct data entry (DDE) claim submission to MassHealth when Medicare and/or a commercial insurer has adjudicated the claim. These instructions supplement the instructions found in the Professional Claim Submission with MassHealth job aid. Providers should follow the instructions described in the Professional Claim Submission with MassHealth job aid, and then refer to this job aid when reporting COB information on the claim. POSC job aids can be found on the web by clicking here. COB DATA ENTRY REQUIREMENTS FOR PROFESSIONAL CLAIMS: Enter the coordination of benefits (COB) information from the Coordination of Benefits tab on the Coordination of Benefits (COB) Detail panel. Do not enter information on the List of COB Reasons panel. On the Procedure tab, enter detail information on the COB Line Item Details and COB Reason Detail panels. COB BALANCING FOR PROFESSIONAL CLAIMS: COB Payer Paid Amount Balancing - For each payer reported in the claim, the total COB Payer Paid Amount entered on the Coordination of Benefits tab must balance to the sum of all the service line other insurance payer paid amounts entered on the List of COB Line Items panel in the Procedure tab minus the claim level HIPAA adjustment amounts entered on the Coordination of Benefits tab. Service Line Billed Amount Balancing - For each payer occurrence of the service line adjudication information, the provider billed amount on the service line entered on the Procedure tab should balance to the sum of the service line other insurance payer paid amount and service line HIPAA- adjustment amounts entered on the Procedure tab. The same HIPAA-adjustment reason codes and amounts cannot be entered on both the Coordination of Benefits tab and Procedure tab. On the Coordination of Benefits Tab On the List of Coordination of Benefits (COB) panel: 1. Click New Item. The Coordination of Benefits (COB) Detail panel displays. On the Coordination of Benefits (COB) Detail panel: 2. In the Carrier Code field, enter the other insurance carrier code. 3. In the Carrier Name field, enter the other insurance carrier name. 4. Do not enter a value in the Remittance Date field. 5. In the Payer Claim number field, enter the other insurance claim number. 6. In the Payer Responsibility field, select the appropriate code from the drop-down list. 7. In the COB Payer Paid Amount field, enter the amount paid by the other insurance. On the Coordination of Benefits Tab (continued) 8. Do not enter a value in the Total Noncovered Amount field. The total noncovered amount should only be entered for authorized TPL exception billing. Refer to supplemental instructions in your provider manual appendix for conditions for which this field may be used. 9. Do not enter a value in the Remaining Patient Liability field. This is not a required field and is not necessary for claims adjudication. 10. In the Claims Filing Indicator field, select the appropriate code from the drop-down list. 11. In the Release of Information field, select the appropriate code from the drop-down list. 12. In the Assignment of Benefits field, select the appropriate code from the drop-down list. 13. In the Relationship to Subscriber field, select the appropriate code from the drop-down list. 14. If you selected “18 – SELF” from the “Relationship to Subscriber” drop down list, then click “Populate Subscriber.” The following data fields that have been entered on the “Billing and Service” tab will be populated. * Subscriber Last Name * Subscriber First Name * Subscriber Address * Subscriber City * Subscriber State * Subscriber Zip Code If you select any other value from “Relationship to Subscriber” drop down list, you must enter the following required fields. * Subscriber Last Name * Subscriber First Name 15. In the Subscriber ID field, enter the other insurance subscriber ID number COB Reasons Detail Panel Data is entered on this panel only when there is a HIPAA-adjustment amount applied to the entire claim that cannot be distributed at the service lines. This amount cannot be entered on both the Coordination of Benefits tab and the Procedure tab otherwise a cob balancing error may occur. On the list of COB Reasons panel: 16. Click New Item. The COB Reasons Detail panel displays. On the COB Reasons Detail panel: 17. In the Group Code field, select the appropriate code identifying the category of payment adjustment from the drop-down list. 18. In the Amount field, enter the adjustment amount associated with the group/reason code. COB Reasons Detail Panel (continued) 19. In the Reason field, enter the reason code identifying the detailed reason the adjustment was made. 20. In the Unit of Service field, enter the units of service being adjusted. 21. Click Add to save the COB Reasons Detail. Note: To report additional COB Reasons, repeat Steps 16-21. 22. Click Add on the Coordination of Benefits (COB) Detail Information panel to save the COB information. Note: To report multiple payers, click New Item on the List of Coordination of Benefits panel, and repeat steps 1-22. On the Procedure Tab On the Procedure tab: 23. Click New Item. Enter Professional Services Detail Panel Providers should follow the instructions described in Professional Claim Submission with MassHealth job aid to complete the Professional Services Detail panel. Then continue with the following steps. Detail COB information must be entered on the COB Line Item Details panel and the COB Reasons Detail panel. On the List of COB Line Items panel: 24. Click New Item. The COB Line Item Details panel displays. On the COB Line Details panel: 25. In the Carrier Code field, carrier code will populate with what has been entered on the “Coordination of Benefits” tab. If there are multiple carrier codes, select the appropriate code from the drop down list. 26. In the Bundled into Line number field, enter the line number only when the other insurance has bundled or unbundled payment for a set of services. 27. In the Remittance Date field, enter the other insurance remittance payment date. 28. In the Paid Amount field, enter the amount paid by the other insurance. 29. In the Paid Units of Service field, enter the number of paid units. 30. Do not enter a value in the Remaining Patient Liability field. This is not a required field and is not necessary for claims adjudication. 31. In the Procedure Code field, enter the appropriate procedure code. 32. In the Modifier fields, enter the modifiers associated with the procedure code if applicable. 33. In the Prior Authorization number field, enter the appropriate authorization number if applicable. This is not a required field and is not necessary for claims adjudication. 34. In the Referral number field, enter the appropriate referral number if applicable. This is not a required field and is not necessary for claims adjudication. Enter Professional Services Detail Panel (continued) On the List of COB Reasons panel: 35. Click New Item. The COB Reasons Detail panel displays. On the COB Reasons Detail panel: 36. In the Group Code field, select the appropriate code identifying the category of payment adjustment from the drop-down list. 37. In the Amount field, enter the adjustment amount associated with the group/reason code. 38. In the Reason field, enter the reason code identifying the detailed reason the adjustment was made. 39. In the Units of Service field, enter the units of service being adjusted. 40. Click Add to save COB Reasons Detail. Note: To report additional COB Reasons, repeat Steps 35-40. 41. Click Add again to save the COB Line Details. Note: To report multiple payers, repeat steps 24-42 42. Click Add again to save the Professional Services Detail panel information. Note: Refer to the Submit a Professional Claim with MassHealth job aid to complete a claim submission. MMIS POSC Job Aid: Professional Claim Submission to MassHealth with Coordination of Benefits Information MassHealth Provider Online Service Center 1 of 5 Effective December 1, 2012 v2.6