Change Request Detail
No.
1171
Date
7/12/2012
Submitter
Type of Request
Professional Claim (HCFA 1500)
Status
DSMO Process Completed
Business Reason
Massachusettsí office of Health Safety Net (HSN) is requesting a segment/element to be added to the 837 Professional that would allow the Community Health Centers notifying HSN whether the patientís deductible is fully met.  This information is needed by HSN for calculating the payment. HSN payment is processed at 80% of what a provider's "full" payment would have been with providers collecting the remaining 20% from the patient and applying it to the patient's deductible, if the deductible was not fully met. Once a patient's deductible has been fully met, HSN payments would be processed at 100%.
Suggestion
Use 2300:K301 to submit the information needed.

2300:K301 Poistion 1 - 2 >>>>> State code  (i.e. MA)
2300:K301 Poistion 3 - 5 >>>>> Division (i.e. HSN)
2300:K301 Position 6 - 80>>>>> required data (i.e. 100)

The 2 possibilites for MA, HSN is:
K3*MAHSN80~
K3*MAHSN100~
DSMO Category
D
Recommendation
Disapprove. Based on the information provided, the DSMO disapprove the request. The requestors need to determine a permanent solution in their systems to capture this information. Providerís cannot be expected to track and report this information to a payer. They have no access to claims processed for other providers, which impact a memberís deductible.
Appeal Recommendation