HIPAA Dental COB ClaimHIPAA Dental COB Claim Mapping Exercise Example

HIPAA Dental COB Claim example and exercise represent how to generate HIPAA Dental COB Claim file for processing by the destination payer.

HIPAA Dental COB Claim Scenario

Patient PUFFY DOG is seen a dentist DONALD D, DUCK in the office INFINITE ENDODONTICS. The payer of the HIPAA Dental COB Claim is MCO Defined with Identifier MCO Defined ID. The dental practice is working with a Clearing house to generate HIPAA Dental COB Claim file to be submitted for processing by the destination payer. The Clearing House assigns a refrence number KS025424659 to the claim for future reference.

The dental service was performed in a different Location called WATERFRONT DENTAL CENTER having NPI = 1710064597. The HIPAA Dental COB Claim has been first adjudicated by the primary insurance and now it is submitted to the secondary insurance for the remainder of the payment.

Information for the HIPAA Dental COB Claim

  • The date of service of the claim is 01/11/2018.
  • Patient PUFFY*DOG has a Subscriber identifier # 970398931 (shared with the spouse CURLY, HOUND)
  • The provider billed the client with $1600
  • He has dental coverage under a different insurance called MY MEDICARE COMPANY with identifier # 12345. The Subscriber of this insurance is CURLY*HOUND with Identifier # 923190575 and relationship code = 01 (spouse)
  • Since this is his Primary insurance (ID = 12345), it pays $100 on 02/02/2018. The rest of the payment is considered to be Patient responsibility and part of it was paid as DEDUCTIBLE = $200, COINSURANCE = $50 and COPAY = $10. There is still $1240 to be covered by the secondary insurance (Destination Payer).

In this exercise you are going to use the correct dollar amounts for each service line keeping in mind that the service must be correctly balanced.

ISA*00* *00* *ZZ*453358287P *ZZ*264595216 *180213*1236*^*00501*000386762*1*P*:~
NM1*41*2*File Load Generator*****46*453358287~
PER*IC*File Load Generator Nicholas Raverty*EM*Communication Number EM Type*TE*8009336593***~
NM1*40*2*File Receiver Organization*****46*264595216~
NM1*85*2*Infinite Endodontics*****XX*1659453926~
N3*526 Cooper St~
NM1*IL*1*PUFFY*DOG****MI*970398931~ — Destination Subscriber
NM1*PR*2*MCO Defined*****PI*MCO Defined ID~ — Destination Payer
NM1*77*2*WATERFRONT DENTAL CENTER*****XX*1710064597~
SBR*P*__2__*******MC~ — Begin Other insurance information (loop 2320)


CAS*PR*1*__4__~ — Claim Deductible
CAS*PR*2*__5__~ — Claim Coinsurance
CAS*PR*3*__6__~ — Claim Copay
CAS*OA*45*__7__~ — Not covered by primary AMT*D*__8__~

— Payer paid amount

AMT*EAF*__9__~ — Remaining Patient liability
OI***Y***Y~ — Other insurance coverage info (Required)
NM1*IL*1*CURLY*HOUND****MI*__3__~ — Other insurer (Required)
NM1*PR*2*MY MEDICARE COMPANY*****PI*__10__~ — Primary insurance (Required)
LX*1~ — Service # 1
DTP*472*D8*20180111~ — Date of service
SVD*12345*0*AD:D3221**1~ — Service # 1 Payment ($0) by the Primary payer (ID=12345)
CAS*PR*1*100~ — Deductible
CAS*PR*2*25~ — Coinsurance
CAS*OA*45*475~ — Not covered amount by the Primary payer
DTP*573*D8*20180202~ — Date service was adjudicated
AMT*EAF*475~ — Remaining patient responsibility
LX*2~ — Service # 2
DTP*472*D8*20180111~  — Date of service

SVD*12345*0*AD:D6093**1~ — Service # 2 Payment ($0) by the Primary payer (ID=12345)
CAS*PR*1*100~ — Deductible
CAS*OA*45*700~ — Not covered amount by the Primary payer
DTP*573*D8*20180202~ — Date service was adjudicated
AMT*EAF*700~ — Remaining patient responsibility
LX*3~ — Service # 3
SVD*12345*__12__*AD:D4278**1~ — Service # 3 Payment ($100) by the Primary payer (ID=12345)
CAS*PR*2*__13__~ — Coinsurance
CAS*PR*3*__14__~ — Copay
CAS*OA*45*__15__~ — Not covered by the Primary DTP*573*D8*20180202~

— Date service was adjudicated

AMT*EAF*__16__~ — Remaining patient responsibility

For the questions under the designated number in the above information, select one of the answers to be considered the ‘best’: The goal of the exercise is to select the correct dollar amount for the service line where the dollar amount is missing, so that the service line will be balanced and will also balance the entire claim.

1 – Billed amount (CLM01)
a. $100
b. $500
c. 1600
d. None of the above
2 – Relationship to Subscriber
a. 01
b. 02
c. 15
d. None of the above
3 – SubscriberID (Both destination subscriber and responsible person share the same SubscriberID)
a. 111333555777
b. 09876543
c. 14576
d. 970398931
e. None of the above
4 – Deductible
a. 10
b. 100
c. 200
d. 600
e. None of the above
5 – Coinsurance
a. 0
b. 20
c. 25
d. 50
e. None of the above
6 – Copay
a. 3
b. 5
c. 10
d. None of the above
7 – Not covered
a. 240
b. 1600
c. 1240
d. None of the above

8 – Payer Paid amount
a. 1600
b. 200
c. 100
d. None of the above
9 – Remaining Patient liability
a. 1500
b. 1240
c. 0
d. None of the above
10 – Primary Insurance ID
a. ABC10
c. 12345
d. None of the above
11 – Service billed by Provider
a. 100
b. 200
c. 300
d. 700
e. None of the above
12 – Service paid by Primary Insurance
a. 0
b. 50
c. 1000
d. 100
e. None of the above
13 – Coinsurance
a. 10
b. 25
c. 100
d. None of the above
14 – Copay
a. 5
b. 15
c. 20
d. 10
e. None of the above

15 – Non covered amount
a. 25
b. 65
c. 145
d. None of the above
16 – Patient responsibility
a. 0
b. 10
c. 15
d. 65
e. None of the above

The main purpose of this claim is to show the requirement for balancing dental claim of a patient who has two insurances (Primary – MY MEDICARE COMPANY, with ID = 12345) and Secondary insurance – MCO Defined with ID = MCO Defined ID).

Each individual service line has to be balanced with the formula:

BA (Billed amount) = PA (Paid amount) + SUM(Adjustments)

This is displayed with information of the following segments:

BA – (Billed amount) = SV302
PA (Paid amount) = SVD02
Adjustments = SUM(CAS03)

Example :
Service # 1 -> 600 = 0 + (100 + 25 + 475)
Service # 2 -> 800 = 0 + (100 + 700)
Service # 3 -> 200 = 100 + (25 + 10 + 65)

To balance the claim level we use the following formula :

Claim BA (CBA) = CPA(claim paid amount) + SUM(CAS segments of all service lines)

CBA – (Claim billed amount) = CLM02
CPA – (Claim paid amount) = AMT*D*02
SUM (Adjustments) = SUM( all Service level CAS segments)

Example :
1600 = 100 + (600 + 800 + 100)
NOTE : Member can have more than one “OTHER INSURANCES”. In the case of more than one insurances, each prior payer (insurance) will have to include their share in the adjudication of the claim by submitting segments from SBR to NM1*PR (loop 2320 through 2330B) in the claim level and also segments from SVD through AMT*EAF for each individual service line as SVD01 = NM1*PR*09 (link of payment to the corresponding Payer).

Dental COB claims are usually submitted with payment and balancing of each service line. In this case, claim level balancing will not be required.

Leave a Reply

Your email address will not be published.

Post Navigation