Electronic claims

Yes, you can send Aetna secondary claims electronically.

Since we support the HIPAA standard for electronic batch claims submission, we can handle COB Claims. This standard allows COB claims to be sent directly from:

• A provider who has received a remittance advice from the previous payer (provider-to-payer COB)
• The previous payer (Payer-to-payer COB)

Not sure what's needed to send in an electronic COB claim? These tips will help you with the fundamentals on what's required, as well as provide you with alternatives, should your practice management system or clearinghouse not be COB-ready.


Tips for Submitting Coordination of Benefits Claims  

To submit COB claims, your practice management system/data entry process and your clearinghouse must be able to:

• Create or forward claims in the full HIPAA standard format (837) or in a format that contains equivalent information and includes necessary COB fields.
• Include payment information received from the primary payer's HIPAA standard electronic remittance advice (ERA) or by converting the primary payer's paper Explanation of Benefits (EOB) into the standard coding used in an ERA (see section on "Converting information" for more details).

Types of COB claims that can be sent electronically

• Commercial insurance claims where another payer is primary and Aetna is secondary.
• Medicare primary claims when Medicare* has not already forwarded us their claim and payment information.

* If the Medicare ERA contains an "MA18" remark code, the claim has crossed over automatically. There is no need to send a Medicare Primary COB claim to us when this occurs. 

Payment information required for commercial electronic COB claims  

• Adjustment amounts - at both claim level and service line level (if available)
• Adjustment reasons - contractual obligation, deductible, coinsurance, etc.
• Primary payer paid amount - at both claim level and service line level (if available)

Payment information required for Medicare primary electronic COB claims  

• Medicare allowed amount - at both claim level and service line level (if available)
• Adjustment amounts - at both claim level and service line level (if available)
• Adjustment reasons - contractual obligation, deductible, coinsurance, etc.
• Medicare paid amount - at both claim level and service line level (if available)
• Patient responsibility amount
• Medicare acceptance of assignment

For more information regarding all required claims elements, please consult with your vendor and/or review COB Data Fields.  (PDF)

Converting information from paper EOBs into industry-standard ERA codes  

When working with a paper EOB, there is an "electronic" way to let us know how the primary payer adjudicated the claim. By using HIPAA-approved code values, you can convert payment information received from the primary payer by paper and transmit it electronically.

• Adjustment Group Code - This code tells us who (the patient or the provider) is responsible for any adjustments made.
• Adjustment Reason Code - This code explains what type of adjustment was made (for example, deductible, coinsurance, write-off amount, etc.).

Note: Your paper remittance may already contain standard code values. If so, please use the codes furnished by the primary payer.

For a comprehensive listing of Adjustment Group and Adjustment Reason codes, please review Adjustment Reason Code and Adjustment Group Code Categorization Table  (PDF). Or, visit the Washington Publishing Company at www.wpc-edi.com to view all HIPAA code lists.

For more information  

Please contact us via email. Simply select "Contact Us" at the top of the screen, then "Doctors & Hospitals", and then "Our Web Site".

Or, contact your practice management support team and/or the clearinghouse through which you submit your electronic claims to inquire about their readiness to transmit electronic COB claims. They may have their own guidelines or tips about submitting COB claims.

Supporting Documents  

These documents provide information on the process of submitting electronic claims.

COB Data Fields  (PDF) provides you with full content of the fields required to submit COB claims online. It references all pertinent data elements (e.g. loops, segments) as found in the ASC X12N 837 Implementation Guide.

Adjustment Reason and Adjustment Group Codes Categorization Table  (PDF) assists you in converting primary payment information received on a paper EOB into industry standard coding.

HIPAA Implementation Guide shows information on the secondary COB claims process in sections 1.4.2 through 1.4.5. To view comparative 837 details on how an electronic COB claim should be presented to Aetna, we've prepared three COB Examples documents, each pertaining to the type of claims you submit:

COB Examples: Professional  (PDF)

COB Examples: Institutional  (PDF)