Change Request Detail
Type of Request
Professional Claim (HCFA 1500)
DSMO Process Completed
Business Reason
As I understand it, as part of the Affordable Care Act, CMS has established a requirement for Health Maintenance Organizations offering Medicare programs (Medicare Advantage - MA) to report the patient coinsurance, co-pay and deductible information.

This requirement is to establish a mandatory maximum out-of-pocket (MOOP) limit on overall cost-sharing for Parts A and B services.

In order to effectively gather and report this information to CMS, the Health Maintenance Organizations are requiring their contracted Independent Physician Associations to submit their professional encounter claims, which are for reporting purposes only, with the coinsurance, co-pay and deductible amounts.

In the 5010 837P transaction, the only way this data can be reported is in a secondary claim.

Billing an encounter claim as secondary is burdensome and there should be a method to report this data on a primary claim if it is now being required.
In the next verson of the X12 837P (and perhaps the X12 837I as well).  Create segments to report this data on a primary claim.
DSMO Category
Disapprove. DSMO were not able identify a requirement from the ACA that applies to Part A and Part B services nor to Medicare Advantage encounter claim requirements.
The submitter can submit additional regulatory documentation, i.e. reference and citation, via the appeal process. The submitter is encouraged to follow-up with CMS Medicare to determine whether there is a need within the 837 claim transaction prior to submitting further requests or an appeal.
Appeal Recommendation