Web Portal Tutorial – TPL and Medicare Secondary Claims (Institutional, Professional and
Dental) 1/9/2012
Institutional Claim – Medicare Secondary/X-Over
Complete the claim as normal, and then complete these additional fields:
• Select the red + before Other Insurance Information • Select the red + before Other Payer Information
o Payer/Insurance Organization Name – Enter the name of the other payer (Medicare)
• Select the red + before Additional Other Payer Information o Adjudication Date - Enter the paid date from the Medicare EOMB
• Select the red + before COB Monetary Amounts o COB Payer Paid Amount - Enter the amount paid by Medicare
• Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information
o Claim Filing Code – Select Medicare from the drop down o Payer Responsibility Sequence Number Code – Select Primary from the drop
down • Select the red + before Other Insurance Coverage
o Benefits Assignment Certification – Select Yes o Release of Information Code – Select Provider Has Signed Release
• From the top of the claim, select the tab that says Other Claim Info
• Select the red + before Claim Level Adjustments o Claim Adjustment Group Code – Select Patient Responsibility o Reason Code – Enter the appropriate code
1 – Deductible 2 – Coinsurance 122 – Psych Deductible
o Amount – Enter the amount assigned to this code
• From the top of the claim, select the tab that says Basic Claim Info • Complete the rest of your claim as normal
Institutional Claim - TPL (other than Medicare)
Complete the claim as normal, then enter these additional fields.
• Select the red + before Other Payer Information o Payer/Insurance Organization Name – Enter the name of the other insurance
• Select the red + before COB Monetary Amounts o COB Payer Paid Amounts – Enter the amount paid by the other insurance
• Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information
o Claim Filing Code – Select the appropriate choice from the drop down o Payer Responsibility Sequence Number Code – Select Primary
• Select the red + before Other Insurance Coverage o Benefits Assignment Certification – Select Yes o Release of Information Code – Select Provider Has Signed Release
Professional Claim – Medicare Secondary/X-Over
Complete the claim as normal, then enter these additional fields.
• Does the subscriber have insurance other than Medicaid – Select yes • Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information
o Claim Filing Code – Select Medicare from the drop down list o Payer Responsibility Sequence Number Code – Select Primary from the drop
down list
• Other Payer Information o Payer/Insurance Organization Name – Enter the name of the insurance
(Medicare) • Additional Other Payer Information
o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be letters, numbers or a combination. You will need to use this again later.
o ID Type – Select Payor Identification from the drop down list o Adjudication Date – Enter the paid date from the Medicare EOMB
• COB Monetary Amounts o COB Payer Paid Amount – Enter the amount Medicare paid
On each line item, after you have entered your line items and added them, complete the following.
• Select the Other Svc Info link at the end of the line item data line
• Select the red + before Service Line Adjudication o Other Payer Primary ID – Enter the same thing entered previously as Other Payer
Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by Medicare for this line item o Adjudicated or Pay Date – Enter the paid date from the Medicare EOMB o Paid Service Unit(s) – Enter the number of units Medicare paid o Procedure Qualifier – Select HCPCS from the drop down list o Procedure Code – Enter the procedure code on this line item
• Select the red + before Service Adjustment o Adjustment Group Code – Select Patient Responsibility from the drop down list o Adjustment Amount – Enter the amount for the adjustment o Adjustment Reason – Enter the appropriate reason code:
1 – Deductible 2 – Coinsurance 122 – Psych Deductible
o Enter up to 5 items as necessary for this line item o Select Add Line Item
• To edit entered adjustment codes, select the Group Code link, moving the items back up to the entry area. When done, select update Line Item
• To delete a whole group code, select the Delete link at the end of the line • When done entering information for this line item, select the Basic Claim Form button
and repeat for each line item on the claim
Professional Claim – TPL (other than Medicare)
Enter the claim as normal, then enter these additional fields.
• Does the subscriber have insurance other than Medicaid – Select yes • Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information
o Claim Filing Code – Select the appropriate type of other insurance from the drop down list
o Payer Responsibility Sequence Number Code – Select Primary from the drop down list
• Other Payer Information o Payer/Insurance Organization Name – Enter the name of the insurance
• Additional Other Payer Information o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be
letters, numbers or a combination. You will need to use this again later. o ID Type – Select Payor Identification from the drop down list
• COB Monetary Amounts o COB Payer Paid Amount – Enter the amount Medicare paid
On each line item, after you have entered your line items and added them, complete the following.
• Select the Other Svc Info link at the end of the line item data line
• Select the red + before Service Line Adjudication o Other Payer Primary ID – Enter the same thing entered previously as Other Payer
Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by the other insurance for this
line item o Adjudicated or Pay Date – Enter the paid date from the other insurance’s EOB o Paid Service Unit(s) – Enter the number of units Medicare paid o Procedure Qualifier – Select HCPCS from the drop down list
o Procedure Code – Enter the procedure code on this line item
• Select the Basic Claim Form to return to the 1st screen of your claim, and repeat these steps for each line item.
Dental Claim – TPL
Enter the claim as normal, then complete these additional fields.
• Does the subscriber have insurance other than Medicaid – Select yes • Payer/Insurance Organization Name – Enter the name of the other insurance • Additional Other Payer Information
o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be letters, numbers or a combination. You will need to use this again later.
o ID Type – Select Payor Identification from the drop down list
On each line item, after you have entered your line items and added them, complete the following.
• Select the Other Svc Info link
• Select the red + before Service Line Adjudication Information o Other Payer Primary ID – Enter the same thing entered previously as Other Payer
Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by the other insurance for this
line item o Adjudicated or Pay Date – Enter the paid date from the other insurance’s EOB o Paid Service Unit(s) – Enter the number of units the other insurance paid o Procedure Qualifier – Select ADA Codes from the drop down list o Procedure Code – Enter the procedure code on this line item
o Select the Basic Claim Form button to return to the 1st page of the claim, repeat these steps for each line item on the claim.