COBC Error Causes ESRD Claims to be Rejected
Several thousand End-Stage Renal Disease (ESRD) facility claims (type of bill 72x) submitted to Highmark Medicare Services between July 5 and Aug. 16 were erroneously rejected. This holds true even if a provider’s Medicare remittance advice indicates that Medicare transferred a patient’s claim to a given supplemental insurer.
The Medicare administrative contractor (MAC) for jurisdiction 12 posted a Provider Bulletin on its website Sept. 27, stating that claims failed to successfully cross over because the Coordination of Benefits Contractor (COBC) translator and edit validation vendor for the Centers for Medicare & Medicaid Services (CMS) did not make necessary accommodations prior to July 5 for the reporting of occurrence code 51, as instructed in CMS change request (CR) 6782. Consequently, the COBC rejected all 72x bills where occurrence code 51 qualifies the Kt/V collection date with edit H51103, which means “51 is not a valid NUBC code.”
Highmark says it has issued a special provider notification letter to facilities in regards to this claims processing error.
The COBC has since made the necessary changes to accept the reporting of the Kt/V collection date, as qualified by 51, on 837 institutional TOB 72x claims. All claims that Medicare contractors sent to the COBC on or after Aug. 16 will not be rejected with code H51103. Due to the current configuration of the COBC translator and edit validator, however, the COBC is unable to re-run the affected claims through its Health Insurance Portability and Accountability Act (HIPAA) edit validation routine to facilitate the crossing over of the affected TOB 72x claims to patients’ supplemental insurers.
CMS has notified all participating supplemental insurers and benefit programs of this issue. Providers should now bill supplemental insurers for any balances remaining following Medicare’s payment determination on their TOB 72x claims.