Your Primary Payer Now Picks Your Medicare Denial

Seven days on the wire: CMS sorted 129 claim adjustment reason codes into four dispositions for every Medicare Secondary Payer claim at Part A, pulled 45 therapy codes off a skilled nursing facility list they should never have been on, terminated one code effective December 31, 2011, and told ambulatory surgical centers to bill a $261,579 gene therapy across ten claims. Plus a favorable OIG opinion on manufacturer-funded premium assistance.

There is a field on your Medicare secondary claim that you are required to fill in and forbidden to change.

It is the claim adjustment segment, the CAS loop that arrives on the primary payer's 835 and rides onto your 837I. CMS is direct about where the contents come from: "The provider must take the CAS segment adjustments, as found on the 835 and report these adjustments on the 837 unchanged, when sending the claim to Medicare for secondary payment."

Your primary payer writes it. You transmit it.

On Friday, CMS published what Medicare does with it. The heaviest of six items on the wire this week.

The rest of this brief is for subscribers.