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Member Health Care Account Payments - Electronic Remittance Advice (835 Transaction) Changes (November 13, 2006)

Effective mid-January 2007, Highmark is making available to members under certain health care programs the option to have their member liability paid directly to the provider from their health care spending account. The member health care spending accounts include Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA). Additional information regarding this new option and the specific programs impacted will be sent to providers and facilities soon. This article identifies the changes being made in January 2007 to the 835 Transaction to accommodate this new option. These changes have been incorporated into the Provider EDI Reference Guide (835 Section) which is available online at www.highmark.com/edi in the Specifications section.

For those providers receiving the Electronic Remittance Advice (ERA), Highmark will create a separate 835 transaction (ST to SE Segment) to document the payment from the member's saving/spending account. This separate or second 835 reporting methodology is termed a “COB reporting model” meaning the member spending account 835 will have the code value attributes of a secondary claim payment. This is an 835 reporting model or methodology, designed to utilize existing automated account posting software functionality and is NOT considered to be the same as a true Payer to Payer COB process for claim adjudication. Highmark will continue to create an 835 transaction to document Highmark's payment. If the member has a saving/spending account, has selected the payment to provider option and has funds available in the account, Highmark will create another 835 transaction to document how the remaining liabilities were addressed by the payment from the member's account. The additional 835 transaction, containing members' health care account payments, will have the same structure as the 835 transactions Highmark currently produces. The health care account 835 transactions (ST to SE Segments) will be included in the Trading Partner's transmission file (ISA to IEA Segments) currently produced for Highmark. Trading Partners will be able to distinguish the health care account 835 by the following features:

  • Loop 1000A, N102 – The Payer Name will be ‘Highmark Health Care Account.'
  • Loop 2100, CLP02 – The Claim Status Code for all claims contained in the 835 transaction will equal ‘2 – Processed as secondary.'
  • Loop 2100 or Loop 2110, CAS Segment – The Claim Adjustment Group and Reason Code will be OA23 for all dollars that equal the difference between the provider's charge and the Patient Responsibility dollars being considered for reimbursement under the account.

Example: 835 Segments Documenting Payment from Highmark and Payment from the Member's Account The example below illustrates the ‘COB reporting model' and 835 segments documenting claim payment from Highmark under the patient's health care coverage plan and reimbursement from the patient's health care account. For purposes of ERA reporting only, Highmark's payment will be treated as ‘primary' and payment from the member's health care account as ‘secondary'.

In this example, the provider's charge is $200. The Highmark allowance for the procedure is $180, leaving a contractual obligation of $20. Highmark applies $130 of that amount to the patient's deductible and pays the remaining $50 to the provider. This is spelled out in the “primary” example below, on the left.

The right side of the example below displays an accounting of the way the member liabilities were handled through the member's saving/spending account, as it would appear on the 835 transaction. The entire patient deductible of $130 is being reimbursed by the member's health care account. The $70 difference ($20 Contractual Obligation plus $50 paid by Highmark) between the $200 charge and the $130 payment from the member's account was assigned a Claim Adjustment Group and Reason code of OA23 – “Other Adjustment/Payment adjusted due to the impact of prior payer(s) adjudication, including payments and/or adjustments.”

See the example below:

Highmark Payment
(Primary)
Highmark Health Care Account Payment (Secondary)
N1^PR^HIGHMARK~
CLP^ABC123^1^200^50^130^12^0123456789~
NM1^QC^1^DOE^JOHN^^^^MI^33344555510~
SVC^HC>99245^200^50~
DTM^150^20060301~
DTM^151^20060304~
CAS^CO^45^20~
CAS^PR^1^130~
N1^PR^HIGHMARK HEALTH CARE ACCOUNT~
CLP^ABC123^2^200^130^^12^0123456789~
NM1^QC^1^DOE^JOHN^^^^MI^33344555510~
SVC^HC>99245^200^130~
DTM^150^20060301~
DTM^151^20060304~
CAS^OA^23^70~