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Back  RFI # 1034: 835 claim adj vs svc adj

Formal vs. Informal Help Informal Formal

Submitter

Kent Dewell

Description

Must an 835 for a professional claim include service-level adjudication details if the adjudication system did not consider the individual service lines? We are a payer that has a Medicare Part B supplemental claims adjudication system which performs the adjudication at the summary (claim) level rather than at the service level. Are we compliant with the 835 IG if we report all payment adjustments within the CLP loop and exclude the SVC loop altogether? Is the answer the same for both v4010 and v5010?

Submitter Assigned Keywords

835 service

Response

This is implicitely stated in the 5010 guide in Section 1.10.2.1.1 and in the 4010 guide in Section 2.2.1.1: “Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim.”

Recommendation

It is the intent of the workgroup and the 835 TR3 that for professional and outpatient claims the servie lines be reported to show the adjustments and payments.
If the payer does service-line pricing then the service lines must be reported to show the adjustment and payments.
Submission 4/28/2010
Status Date 7/12/2010
Status F - Final
Primary References
Document 005010X221
Section2
Page186
Set ID835
Table2
Loop2110
Segment Position0700
Segment IDSVC
Secondary References
RFI ID 942
Document 005010X221
Section1.10.2.1
Page14
Set ID835