In order to ensure proper adjudication of claims involving a prior payer, it is strongly recommended that the TRICARE East Region receives the prior payer information and a reason if there is no prior payment on the claim(s) submitted. TRICARE East follows the ASC X12 837 Implementation Guides for the needed elements to process these types of claims. The following outline provides the basic elements of the 837, which are needed 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.