In the near future, WellCare of New Jersey Medicaid will activate a Strategic National Implementation Process (SNIP) edit which will require all TPV encounter submissions to include the COB prior payment information.
This SNIP edit will align WellCare’s obligation for reporting all valid services to the State for utilization management. We continue to be committed to helping you submit clean electronic institutional (837I) and professional (837P) submissions. Please see the below instructions for billing COB prior payment information from the Encounter 837P and 837I Companion Guides.
All New Jersey Medicaid TPV Submitters that adjudicate Encounters for The Plan HMO or have COB information from other payers are required to send in all the Coordination of Benefits and Adjudication Loops as per the Coordination of Benefits 1.4.1 section within the 837 Institutional and Professional (TR3) Implementation Guides.
Rejection Description – Claim payment missing/invalid.
It is important that you/your organization comply with these submission requirements in order for your claims/encounters to be processed in a timely manner and to avoid rejections.
5010 Electronic Encounters Companion Guidance:
837P (Professional)
The required loops and segments that are needed to be sent for a compliant COB are as follows:
• Other Subscriber Information (2320) Loop
• Other Subscriber Name (2330A) Loop
-Line Adjudication Information (2430) Loop o For out-of-pocket amounts, use Loop ID 2430 220 Position 300 Data Element 782 for Patient Responsibility
-This includes coinsurance, co-pays and deductibles – Please refer to Code Set 139 for the correct Encounters Adjustment Reason Code
837I (Institutional)
The required Loops and Segments that are needed to be sent for a Compliant COB are as follows:
• Other Subscriber Information (2320) Loop
• Other Subscriber Name (2330A) Loop
-Line Adjudication Information (2430) Loop o For Out-of-Pocket amounts, use Loop ID 2430 220 Position 300 Data Element 782 for Patient Responsibility
-This includes Coinsurance, Co-pays and Deductibles – Please refer to Code Set 139 for the correct Encounter Adjustment Reason Code
Resource Link: Professional and Institutional Encounter Companion Guides
https://www.wellcare.com/New-Jersey/Providers/Medicaid/Claims
For additional information, providers can reach out to our EDI Department at EDI-Master@wellcare.com.