To ensure accurate adjudication of claims involving a prior payer, it is strongly recommended to include prior payer information and a reason when no prior payment exists on the submitted claim(s). The ASC X12 837 Implementation Guides should be followed to include the necessary elements for processing such claims. The outline below highlights the essential components of the 837 required for coordination of benefits claim processing.
SBR—Other Subscriber Information: The 2320 loop is required when reporting other insurance, prior or otherwise. The multiple instances of SBR segments break down multiple payers and their adjudication information.
AMT—Prior Payer Paid: The 837 Implementation Guides require this element if the claim was adjudicated by a prior payer.
OI—Other Insurance Coverage Information: Required when 2320/SBR is reported.
CAS—Claim Level Adjustments/Line Adjustments: The CAS segments, as described in the 837 Implementation Guides, indicate the CAS usage to report prior payer adjustments that cause the amount paid to differ from the amount originally charged. Report Claim Adjustment Reason Codes (CARC) and associated dollar amounts at the same level as received from the prior payer.
NM1—Other Subscriber’s Name: The 837 Implementation Guides require this segment if Loop 2320 is present.
NM1—Other Payer Name: The 837 Implementation Guides require this segment if Loop 2320 is present.
DTP—Claim Check or Remittance Date: The 837 Implementation Guides require this segment when the line adjudication date is not used and the prior payer has adjudicated the claim.