Activation of New Coordination of Benefits Agreement (COBA) Trading Partner Dispute Error Code Within the National Crossover Process
MLN Matters® Number: MM6640
Related Change Request (CR) #: 6640
Related CR Release Date: September 25, 2009
Effective Date: October 26, 2009
Related CR Transmittal #: R562OTN
Implementation Date: October 26, 2009
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (Carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6640, which conveys a new COBA trading partner dispute error code that the Coordination of Benefits Contractor (COBC) will return to Medicare contractors when certain claims are not accepted by supplemental payers. Billing staff should be aware of this change.
Background
The Coordination of Benefits Contractor (COBC) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The Centers for Medicare & Medicaid Services (CMS) developed and further refined the COBC Detailed Error Report process through the issuance of Change Request 3709 (See Transmittals 474, dated February 11, 2005, at www.cms.hhs.gov/transmittals/downloads/R474CP.pdf (PDF, 103 KB) on the CMS Web site) and CR 5472 (See Transmittal 1189 dated February 28, 2007, at www.cms.hhs.gov/Transmittals/Downloads/R1189CP.pdf (PDF, 1.08 MB) on the CMS Web site).
Under the COBC Detailed Error Report process, the COBC reports to Medicare contractors, via a standard Detailed Error Report layout, any of the following error conditions that resulted in their claims not being crossed over:
- Incoming flat file contained structural problems (“111” flat file errors);
- Incoming flat file contained claims with Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) compliance errors (“222” errors); and
- The COBA trading partner rejected the contractors’ claims (“333” trading partner dispute errors).
NOTE: Crossover is the transfer of processed claim data from Medicare operations to commercial insurance companies that sell supplemental insurance benefits to Medicare beneficiaries and to Medicaid (or state) agencies.
Depending upon the error percentage encountered in association with errored claims, Medicare contractors then, after five (5) business days, automatically generate special provider notification letters informing the affected physician/supplier/provider that the beneficiary’s claim(s) cannot be crossed over.
In earlier instructions CMS directed Medicare contractors to suppress creation of their standard provider notification letters when they receive any of the following “333” dispute reason codes via the COBC Detailed Error Reports:
- 00100—duplicate claim;
- 000110—duplicate claim within the same ISA-IEA loop; and
- 000120—duplicate claim within the same ST-SE loop.
CMS made this decision primarily for two reasons:
- It was believed that these particular error conditions were out of the control of the billing provider; and
- It would be futile for the provider to bill the claims to the COBA trading partner outside the crossover process given that the entity had already received the claim, as witnessed by its lodging of a dispute on the basis of duplicate claim receipt.
Currently, the only in-use “333” dispute codes that will trigger provider notification letters are the following:
- 000200 — Claim for provider ID/state should have been excluded; 000300—beneficiary not on eligibility-file;
- 000500 — Incorrect claim count; 000600—claim does not meet selection criteria;
- 000700 — HIPAA Error; and
- 009999 — Other.
Through CR 6640, the COBC will activate dispute reason code 000400 (previously reserved for future use) as a new “333” trading partner dispute code. As a result of this action, the COBC will:
- Transmit error code 000400 to Medicare contractor when indicated via the COBC Detailed Error Report; and
- Include within the error description field on the COBC Detailed Error Report the following standard message: “No provider agreement with Medicaid/other payer; claims crossover not possible.”
Also, as a result of CR6640, all Medicare contractors will generate error code 000400 when received via their COBC Detailed Error Report with accompanying error message on their outgoing notification letters to providers, physicians, or suppliers. As indicated in CR 6640, upon receipt of the contractor-generated special letters, affected providers, physicians, or suppliers may wish to contact their patient’s indicated supplemental payer to determine next steps.
Additional Information
The official instruction, CR 6640, issued to your Carrier, FI, A/B MAC, RHHI, and DME MAC regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R562OTN.pdf (PDF, 109 KB) on the CMS Web site.
If you have any questions, please contact our provider service center at our toll-free number, (877) 567-9249 (for North Carolina and South Carolina Part A providers) or (866) 801-5301 (for home health and hospice providers).
Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.