User Guide — eSecondaries FAQ

An eSecondary claim is a claim submitted to a secondary payer electronically. The ANSI X12 837 standards provide a way to report this Coordination of Benefits (COB) information directly in the electronic format, without the need for paper.

The main benefits of eSecondaries are operational efficiency, reduced DAR, and Medicare compliance. Operational efficiencies are obtained by reducing the amount of manual work required to print secondary claims, collate the claims with the appropriate EOB, and send the claims via mail. Additionally, DAR for secondary claims can be reduced because the secondary payer receives the claim much more quickly. Lastly, eSecondaries enable athenahealth to comply with Medicare regulations mandating electronic submission of all "initial" claims in all but a few circumstances.

An eSecondary claim differs from an ePrimary claim in three main ways:

1. The subscriber information printed in Loop 2010BA and the payer information printed in Loop 2010BB contain information related to the patient's secondary policy rather than the primary policy.
2. Identification numbers, such as the Supervising Provider's number, are those issued by the secondary payer rather than the primary payer.
3. Additional Coordination of Benefits (COB) fields of information are reported, including primary payer prior payments, contractual adjustments, and patient responsibility amounts.

eSecondary claims can be transmitted using one of two models.

The first model, called Provider > Payer > Payer, works as follows:

• Provider submits an ANSI 837 to the primary payer.
• Primary payer adjudicates the claim and either sends an ANSI 835 (ERA) or paper remit to the provider. Remit will include a code indicating that the claim was crossed over.
• Primary payer will send an ANSI 837 with the COB data to the secondary payer.

The second model, called Provider > Payer > Provider, works as follows:

• Provider submits an ANSI 837 to the primary payer.
• Primary payer adjudicates the claim and either sends an ANSI 835 (ERA) or paper remit to the provider.
• Provider submits an ANSI 837 with the COB data to the secondary payer.

Medicare Secondary payer (MSP) claims are claims where Medicare is the secondary payer. Medicare may be secondary for claims involving Black Lung, ESRD, Worker's Comp, etc. MSP claims have different requirements from other claims when submitted electronically.

Beyond those requirements specified in the ANSI 837 Implementation Guide, Medicare also requires two additional pieces of information: The line-level allowed amount and the line-level OTAF amount. The OTAF amount is the amount that the provider is obligated to accept as payment in full for a particular line item.