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March 10, 2003

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Coordination of Benefits Crossover Claims - Additional April 2003 System Changes

NOTE: This article contains information that may now be out-of-date or may have been updated with a more current article or policy. Primarily, 4010A1 will be the format required for ANSI X.12 after October 16, 2003.

Beginning April 7, 2003:

• Our system will support X12 N 837 (4010A1) COB transaction according to Addenda Implementation Guide of ASC X12N 837 (004010X0980A1). CIGNA Government Services will be ready to begin to schedule testing and transitioning of COB partners on version 4010A1 by April 1, 2003.
• Medicare plans to switch to exclusive use of the version 4010A1 by October 16, 2003.
• Each trading partner that elected to exchange COB electronically must accept version 4010A1 by October 16, 2003.
• The addenda pages may be found at http://hipaa.wpc-edi.com/HIPAAAddenda_40.asp.
• The following changes will be made to our system according to Addenda requirements:
  1. Our system will support both versions 4010 and 4010A1 for 837 COB transactions until October 16, 2003 or until further instructions from CMS.
  2. Our system will allow an additional valid value "004010X098A1" in the GS08 element in Functional Group and REF02 element in Header.
  3. All N2 segments used to report additional name data will not present on the 837 (4010A1) COB transactions.
  4. The segment PRV in the loops 2000A, 2310A, 2310B, 2420A and 2420F will be present on 837 (4010A1) COB transactions only if received on 837 (4010) or 837 (4010A1) inbound. This segment will be not created for 'skinny' claims.
  5. In the segments 2000B|PAT and 2000C|PAT the valid value for the data element PAT07 will be "01" (pounds). Data elements PAT07 and PAT08 will be not present on the 837 (4010A1) COB transactions when the incoming claim is paper or a non-HIPAA format ('skinny' claims).
  6. Elements 2300|CLM11-1, 2300|CLM11-2 and 2300|CLM11-3 will have value "OA" on the 837 (4010A1) COB transaction if they have value 'AB' on 837 (4010) incoming transaction.
  7. Segments 2300|DTP and 2400|DTP will not present on 837 (4010A1) COB for Order Date (DTP01 = '938'), Referral Date (DTP01 = '330') and Estimated Birth Date (DTP = 'ABC').
  8. The segment 2300|DTP will be present on 837 (4010A1) COB for Date - Initial Treatment (DTP01 = '454') for claims involving spinal manipulation with procedure codes 98940, 98941 and 98942 only.
  9. In the segments 2300|CR2 and 2400|CR2 the following Chiropractic Certification fields will be not present on 837 (4010A1) COB transactions: 2300|CRC01 - 2300|CR207, 2300|CRC09, 2400|CRC01 - 2400|CR207, 2400|CR209.
  10. New segment CRC "EPSDT Referral" in the loop 2300 will be present on the 837 (4010A1) COB transaction only when received on the 837 (4010A1) incoming transaction. If the element CRC02 will require "gap filling" the segment CRC "EPSDT Referral" will not be created on the 837 (4010A1) outbound. If elements CRC03, CRC04 and CRC05 will require "gap filling" then the value 'NU' will be used when CRC02 = 'N' and the segment CRC "EPSDT Referral" will not be created on the 837 4010A1 outbound when CRC02 = 'Y'.
  11. The element 2310C|NM103 will be present and 2420B|NM103 will not be present on the 837 (4010A1) COB transactions. If the element 2310C|NM103 will require "gap filling" then the value "UNKNOWN" will be used. If the element 2310C|NM102 is equal "1" on 837 (4010A1) inbound and elements 2310C|NM104 and 2310C|NM105 will require "gap filling" then the value "UNKNOWN" will be used.
  12. Only elements NM101 and NM102 in the loops 2330C, 2330D, 2330E, 2330F, 2330G and 2330H will be present on the 837 (4010A1) COB transactions.
  13. The segment 2400|SV4 will be not present on the 837 (4010A1) COB transactions.
  14. The new segment 2400|SV5 will be present on the 837 (4010A1) COB transaction only if received on COB837 (4010A1) inbound. This segment will be not created for 'skinny' claims. If the element 2400|SV501-2 will require "gap filling" then the value "UNKNOWN" will be used. If the element 2400|SV503 will require "gap filling" then the value zero will be used.
  15. The segment 2400|QTY will be not present on the 837 (4010A1) COB transactions.
  16. The new loop 2410 with segments LIN, CTP and REF is present on the 837 (4010A1) COB transactions only if the required information will be received on the incoming claim. If the element 2400|LIN03 will require "gap filling" then the value "UNKNOWN" will be used. If elements 2400|CTP03 or 2400|CTP04 will require "gap filling" then the value zero will be used. If the element 2400|CTP05-1 will require "gap filling" then the value "UN" will be used.
  17. For all other data elements used in 837 version 4010 that belong also to 837 version 4010A1 articles "October 2002 changes for X12N 837 (4010) Coordination of Benefits" posted on 09.27.02 and "April 2003 system changes for Coordination of Benefits" posted on 02.11.03 provide the information about "gap filling" data when issuing an outbound X12N 837 (4010) COB transaction to generate files with complete, HIPAA compliant data elements. In addition to the information included in these articles:
      • Item 3 in the "October 2002 changes for X12N 837 (4010) Coordination of Benefits" article has been changed to reflect the following: All NM103, NM104, NM105, NM107, PER02, PER04 (exception 2010AA loop), PER06, PER08, N201, N301, N302, REF02, CN104, CN106, K301, NTE02, CR109, CR110, CR210, CR211, MOA03, MOA04, MOA05, MOA06, MOA07, HI101-2, HI102-2, HI103-2, HI104-2, HI105-2, HI105-2, HI106-2, HI107-2, HI108-2, HCP04, HCP06, SV101-2, PS101, HCP04, HCP06 and HCP10 and fields will be evaluated for compliance and will be "gap filled" with "UNKNOWN". The element 2010AA|PER04 will have value "NOTSUBMITTED".
      • The elements 2310D|NM103, 2310D|301 and 2310D|N402 will have value "SUBMITTED BUT NOT FORWARDED" on the 837 (4010) and (4010 A1) COB transactions for 'skinny' incoming claims due to our system design.

Reminder! As a government contractor, CIGNA Government Services is required to follow instructions provided by the Centers for Medicare & Medicaid Services (CMS). The CMS Web site that provides information about our system changes can be accessed at http://cms.hhs.gov/manuals (select the section for Program Memoranda/Program Memos). For example, AB-03-026 file is for 837 Addenda version 4010A1 and B-03-012 file is for NDC codes.

Contact information. If you have questions regarding this article or related to Coordination of Benefits, please call us at 615.782.4500 x24206 or send your questions by e-mail.

October 16, 2003. Are you ready? For the latest updates on the October 16 HIPAA deadline and to learn more about transaction and code set requirements, visit the HIPAA Information Center at www.cignamedicare.com/hipaa.

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