MN–ITS Help – 837P and 837D COB – TPL/Medicare

The table below describes the individual fields on the Coordination of Benefits (COB) screens. * The Field Name column identifies X12 loops and elements only for fields that display in the MN–ITS screens. Refer to the X12 HIPAA Companion Guides available through the WPC X12 Registry for additional instruction when submitting batch claims.

Select MN–ITS User Guides to obtain additional instruction for submitting claims for specific services using MN–ITS Direct Data Entry (DDE).

MN-ITS Interactive COB Tab, Field Completion Guide is a supplemental guide that will help you complete the MN-ITS interactive Coordination of Benefits tab.

Field Name*
(X12 Loop & Element)

Valid Values

Character Length

Field Description

Other Payer Name
(Loop: 2330B, NM103)

 

60
(alphanumeric)

Full name of the insurance carrier

Other Payer Primary ID
(Loop: 2330B, NM109)

 

80
(alphanumeric)

Identifier of the insurance carrier or the Medicare contractor NPI

Claim Filing Indicator
(Loop: 2320, SBR09)

Refer to the MN–ITS screen for values available

 

Code identifying type of insurance

Payer Responsibility
(Loop: 2320, SBR01)

Refer to the MN–ITS screen for values available

 

Code identifying the insurance carrier’s level of responsibility for payment of a claim

Insured ID
(Loop: 2330A, NM109)

 

80
(alphanumeric)

The policy holder’s identification number as assigned by the payer

Relationship Code
(Loop: 2320, SBR02)

Refer to the MN–ITS screen for values available

 

The relationship of the MHCP subscriber (recipient) to the policy holder

Claim Adjustment Group Code
(Loop: 2320, CAS01)

Refer to the MN–ITS screen for values available

 

Code identifying the general category used to describe the type of adjustment

Used for TPL only

Adj Reason Code
(Loop: 2320, CAS02, CAS05, CAS08, CAS11, CAS14, CAS17)

Refer to other payer EOB or EOMB

5
(alphanumeric)

Code identifying the detailed reason the claim paid differently than originally billed, by the provider, to the other payer

Used for TPL only

Adj Amount  
(Loop: 2320, CAS03, CAS06, CAS09, CAS12, CAS15 CAS18)

 

10
(numeric)

The dollar amount of the adjustment

Used for TPL only

Adj Quantity
(Loop: 2320, CAS04, CAS07, CAS10, CAS13, CAS16, CAS19)

 

15
(numeric)

The units of service being adjusted

Used for TPL only

Payer Paid Amount
(Loop: 2320, AMT02)

 

10
(numeric)

The total dollar amount paid by the other payer

Non-Covered Charge Amount
(Loop: 2320, AMT02)

 

10
(numeric)

The total dollar amount the other payer did not pay

Other Payers Claim Control Number
(Loop: 2330B, REF02)

Refer to Medicare EOMB

50
(alphanumeric)

The claim number reported on the Medicare EOMB

Reimbursement Rate
(Loop: 2320, MOA01)

Refer to Medicare EOMB

10
(numeric)

Reimbursement rate from the EOMB

Report only if on the Medicare EOMB

End Stage Renal Disease Payment Amount
(Loop: 2320, MOA08)

Refer to Medicare EOMB

10
(numeric)

End Stage Renal Disease (ESRD) payment amount from the EOMB

Report only if on the Medicare EOMB

HCPC Payable Amount
(Loop: 2320, MOA02)

Refer to Medicare EOMB

10
(numeric)

The claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount from the EOMB

Report only if on the Medicare EOMB

Non-Payable Professional Component Amount
(Loop: 2320, MOA09)

Refer to Medicare EOMB

18
(numeric)

Not used by MHCP

Other Payers Claim Control Number
(Loop: 2330B, REF02)

Refer to Medicare EOMB

50
(alphanumeric)

The claim number reported on the Medicare EOMB

Payment Remark Code
(Loop: 2320, MOA03-MOA07)

Refer to Medicare EOMB

50
(alphanumeric)

The remittance advice remark codes reported on the Medicare EOMB

Report only if on the Medicare EOMB

Benefits Assignment
(Loop: 2320, O103)

Yes - Benefits assigned to the provider

No - Benefits not assigned to the provider

Not Applicable - Patient refuses to assign benefits

 

The determination of the policy holder or person authorized to act on their behalf, to give the other payer permission to pay the provider directly

Default is Yes

Release of Information
(Loop 2320, O106)

Yes - Signature collected or required

Informed Consent - Signature not collected and not required

 

The determination of whether the provider has on file a signed statement by the recipient authorizing the release of medical data to other organizations

Default is Yes