on 4/26/2021 at 2:18 PM

Withdrawn - IRR CLM919 Settlements requiring more than five Payment Segments


From: Gregg Lutz

User Posts: 472 - Intermediate User

Download Attachment IRR CLM919 - Settlements requiring more than 5 Payment Segments.pdf 91.44 kB 12 downloads

Business Requirement / Issue: Settlements requiring more than five Payment Segments.

Requester's Proposed Resolution: Determine best way to handle this scenario within the Standard.

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on 8/30/2021 at 6:26 PM

From: Gregg Lutz

User Posts: 472 - Intermediate User

This IRR was withdrawn by Minnesota.

on 8/19/2021 at 2:10 PM

From: Monica Blackwell

User Posts: 33 - New User

The workgroup met over the last couple of weeks and determined the following.  Medical Intervener Payments in Minnesota were being coded to Benefit Type Code 501 and after much discussion, we determined that these payments should have been coded to their respective Other Benefit Type Codes.  We believe when these payments are coded correctly to OBTs, this alleviates the immediate issue of exceeding 5 Payment segments on Settlements.  Minnesota and the workgroup have agreed that this IRR can be withdrawn.     

on 7/1/2021 at 7:23 PM

From: Monica Blackwell

User Posts: 33 - New User

Claims Committee members,

Please review this proposed resolution (in progress) prior to the July 21st Claims Committee meeting.  We will be discussing the idea we have for resolving this IRR within the R3.1 constraints of a maximum of 5 Payment segments.

The workgroup is exploring the idea of creating a high level hierarchy when more than 5 payment segments are present on a single transaction.  We have made an assumption that indemnity settlement payments (in no particular order) would take priority over medical settlement payments and OBT payments. 

Example problem statement:  Benefit Type Codes (BTC) 500 and 501 are present on a claim.  Only BTC 501 (medical portion) is present in the Payment Segment because the maximum of 5 Payments Segments has been reached.  There is no room for BTC 500 payments to be present on the transaction.

Proposal:  If you have more than 5 payment segments, the first 5 would be populated with the 5xx series, other than 501 and, if you exceed the 5 payment segments with the 5xx, all remaining payments would be omitted, including any OBT Payment Reason Codes. If there are any available Payment Reason Code segments left over, 501 and OBTs may be reported.

If you don’t have 5xx payment segments to report, then report 501 and OBTs as necessary up to the 5 maximum payment segments allowed.

Examples based on the problem statement above: 

  1. Payment Reason Codes paid:
     

500

Unspecified Lump Sum

Payee 1

500

Unspecified Lump Sum

Payee 2

500

Unspecified Lump Sum

Payee 3

500

Unspecified Lump Sum

Payee 4

501

Medical Lump Sum

Payee 5

500

Unspecified Lump Sum

Payee 6

500

Unspecified Lump Sum

Payee 7

Populated Transaction would contain the following with Payment Reason Codes 500 (indemnity portion) taking priority:

     

500

Unspecified Lump Sum

Payee 1

500

Unspecified Lump Sum

Payee 2

500

Unspecified Lump Sum

Payee 3

500

Unspecified Lump Sum

Payee 4

500

Unspecified Lump Sum

Payee 6

  1. Payment Reason Codes paid:
     

501

Medical Lump Sum

Payee 1

501

Medical Lump Sum

Payee 2

500

Unspecified Lump Sum

Payee 3

500

Unspecified Lump Sum

Payee 4

501

Medical Lump Sum

Payee 5

500

Unspecified Lump Sum

Payee 6

Populated Transaction would contain the following with Payment Reason Code 500 (indemnity portion) taking priority:

     

500

Unspecified Lump Sum

Payee 3

500

Unspecified Lump Sum

Payee 4

500

Unspecified Lump Sum

Payee 6

501

Medical Lump Sum

Payee 1 (or may be Payee 2 or Payee 5)

501

Medical Lump Sum

Payee 2 (or may be Payee 1 or Payee 5)

              There is no requirement around which Medical Lump Sum Payees should be populated.

on 5/17/2021 at 3:40 PM

From: Monica Blackwell

User Posts: 33 - New User

Just a quick update for everyone....... A workgroup is being formed to address this IRR.  We have received volunteers from our discussion at the Forum and meetings will be scheduled soon. 

on 4/26/2021 at 2:20 PM

From: Gregg Lutz

User Posts: 472 - Intermediate User

The EDI Claims Committee is seeking voluteers to participate in a work group for this IRR. Please respond to the following poll if you wish to volunteer: https://doodle.com/poll/bbwe6r972z6zrccw?utm_source=poll&utm_medium=link