Change Request Detail
Type of Request
Professional Claim (HCFA 1500)
DSMO Process Completed
Business Reason
CMS is seeking a change to the HIPAA standard for the ASC X12 837 professional claim transaction in order to process Medicare subrogation claims.
In accordance with 42 U.S.C. 1395u(b)(6)(B); and 42 C.F.R. 424.66, Medicare is required to pay Part B claims under an Indirect Payment Procedure (IPP) to qualifying entities under qualifying conditions.  In this IPP, the entity seeking payment has provided a complementary health benefit plan to a Medicare beneficiary and has paid a Medicare provider for the services the beneficiary has received.  Medicare is required to reimburse the IPP (when certain qualifications are met). Currently Medicare is processing these claims via paper.  While the current volume of paper IPP claims is manageable, we anticipate more complementary health plans to become registered to submit IPP claims, and the volume of IPP claims to increase significantly over time.  Therefore, CMS would like to establish a process for submitting these claims electronically as soon as possible; however, the 2010AC loop usage is restricted to Medicaid subrogation.
A possible way to accommodate this business need is to change loop 2010AC (Pay-to Plan Name Loop) such that it can accommodate subrogation claims other than Medicaid. The current requirement  that "this loop may be used only when BHT06=31" appear to mean that it can apply only to Medicaid subrogation claims.  The definition of code 31 is "Subrogation Demand  The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners...."; we are open to suggestions, however.
DSMO Category
Approve. ASC X12 will define the technical solution for inclusion in a future version.
Appeal Recommendation