1) On an 837I or 837P 5010 claim is it required to always have at least one SBR01=P whether it is in Loop ID-2000B or Loop ID-2320? Example: A patient have Medicare/Medicaid. The Medicare benefits are exhausted on 09/24/14. A claim is submitted to Medicaid for 09/25/14 and foward with Medicaid in 2010BB & 2000B-SBR01=S. Because the Medicare benefits were exhausted on 9/24, Loop ID 2320 was not reported with Medicare as the primary payer because we interpret the Situational Rule for 2320-SBR as only report payers that are paying on THIS claim statement date which Medicare was no longer responsible. Should the Medicaid 2000B-SBR01 be changed from an S to P in this instance or should Medicare still be reported on the 2320 even though it has no financial responsibility for the 837 claim dates? Note: We have some payers that have rejected 837 claims for a payer NOT financially responsible being on the claim and some stating that because there is not an SBR01=P on the claim it's a non-compliant claim.
The situational rule on the 2320 loop SBR segment reads "Required when other payers are known to potentially be involved in paying on this claim." The operative there is "potentially be involved in paying". There is no restriction that payers reported must be paying. All of the COB models listed in section 1.4.1.1 start with payer A being identified as the primary payer, and includes the primary payer information in the claim to the secondary payer. Therefore, there must be a primary payer reported in either the 2000B SBR01 or the 2320 SBR01. For the scenario stated, even though Medicare did not pay, Medicare must be reported as primary in the secondary claim to pass the Medicare rejection information on to the secondary payer (Medicaid), since Medicare was potentially involved in paying. It is only by reporting the Medicare rejection to Medicaid that Medicaid knows the result of the potential Medicare involvement. On the claim to Medicaid, Medicare should be reported as primary in the 2320 loop and Medicaid should be reported as secondary in the 2000B loop.