This job aid reviews the process of submitting an electronic Institutional 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 Institutional 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 Institutional Claim Submission with MassHealth job aid. Providers should follow the instructions described in the Institutional 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 INSTITUTIONAL CLAIMS For inpatient and nursing facility room and board claims, enter the COB information on the Coordination of Benefits tab on the following panels: * Coordination of Benefits (COB) Detail; and * List of COB Reasons. Do not repeat this information on the Procedure tab. For Institutional claims that are not inpatient or nursing facility room and board claims, enter the COB information on the Coordination of Benefits tab on the Coordination of Benefits (COB) Detail panel. Do not enter information on the List of COB Reasons panel. From the Procedure tab, enter detail cob information on the COB Line Item Details and COB Reason Detail panels. COB BALANCING FOR INSTITUTIONAL CLAIMS Claim Billed Amount Balancing - For inpatient and nursing facility room and board claims, for each payer reported in the claim, the sum of the payer paid amount and HIPAA-adjustment amounts entered on the Coordination of Benefits tab should balance to the Total Charges entered on the Billing and Services tab. COB Payer Paid Amount Balancing - For Institutional claims that are not inpatient or nursing facility room and board, 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 Institutional claims that are not inpatient or nursing facility room and board, 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. For Institutional claims that are not inpatient or nursing facility room and board, the same HIPAA- adjustment reason codes and amounts cannot be entered on both the Coordination of Benefits tab and Procedure tab. REMITTANCE DATE The Remittance Date is critical for COB claims adjudication. The Remittance Date cannot be entered on both the Coordination of Benefits and Procedure tabs. For inpatient and nursing facility room and board claims enter the Remittance Date on the Coordination of Benefits tab and do not enter on the Procedure tab. For claims that are not inpatient or nursing facility room and board, enter the Remittance Date on the Procedure tab and do not enter on the Coordination of Benefits 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. For a Medicare claim submission, enter 0084000. 3. In the Carrier Name field, enter the other insurance carrier name. 4. In the Remittance Date field, enter the remittance date for inpatient and nursing facility room and board claims only. Do not enter a remittance date for claims that are not inpatient or nursing facility room and board. 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. 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 For inpatient and nursing facility room and board claims, complete this panel. Do not repeat this information on the Procedure tab. For Institutional claims that are not inpatient or nursing facility room and board, data is entered 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. 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. 19. In the Unit of Service field, enter the units of service being adjusted. 20. In the Reason field, enter the reason code identifying the detailed reason the adjustment was made. 21. Click Add to save 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, then repeat steps 1-22. On the Procedure Tab On the Procedure tab: 23. Click New Item. Enter Institutional Service Detail Panel Providers should follow the instructions described in Institutional Claim Submission with MassHealth job aid to complete the Institutional Service Detail panel. Then continue with the following steps. For Institutional claims that are not inpatient or nursing facility room and board, the 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. COB Line Details Panel (continued) 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 date for all claims that are not inpatient or nursing facility room and board. 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. In the Revenue Code field, enter the appropriate revenue code. 31. Do not enter a value in the Remaining Patient Liability field. This is not a required field and is not necessary for claims adjudication. 32. In the Procedure Code field, enter the procedure code associated with the revenue code if applicable. 33. In the Modifier fields, enter the modifiers associated with the procedure code if applicable. On the List of COB Reasons panel: 34. Click New Item. The COB Reasons Detail panel displays. On the COB Reasons Detail panel: 35. In the Group Code field, select the appropriate code identifying the category of payment adjustment from the drop-down list. 36. In the Amount field, enter the adjustment amount associated with the group/reason code. 37. In the Units of Service field, enter the units of service being adjusted. 38. In the Reason field, enter the reason code identifying the detailed reason the adjustment was made. 39. Click Add to save COB Reasons Detail. Note: To report additional COB Reasons, repeat Steps 34-39. 40. Click Add again to save the COB Line Details. Note: To report multiple payers, repeat steps 24-41. 41. Click Add again to save the Institutional Service Detail panel information. Note: Refer to the Institutional Claim Submission with MassHealth job aid to complete a claim submission. MMIS POSC Job Aid: Institutional Claim Submission to MassHealth with Coordination of Benefits Information MassHealth Provider Online Service Center 1 of 4 Effective December 1, 2012 v2.7