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Back  RFI # 1109: Clarification on HIR 1060

Formal vs. Informal Help Informal Formal

Submitter

Jan Klimper

Description

Scenario:
An adjudication system has not yet remediated to 5010, so all claims (i.e. paper, electronic, 4010 and 5010 837's) are processed as 4010.
The separate financial system has remediated and is only creating 5010 835's. AND, the provider is set up to receive 5010 835's.
There are some situational fields that when billed on a 5010 837, the must be returned on a 5010 835. (Ex: 2110 SVC06-7).
If the adjudication is not currently capturing this data today, and can't until remidiation, are we compliant?

Submitter Assigned Keywords

4010 837 5010 835

Response

The composite element SVC06 usage is dependent upon whether the procedure in SVC01 is a different procedure than what was submitted on the original claim.

The general procedure description requirement for SVC06-7, in both version 4010 and 5010, is: If the composite is being used and a description was submitted for the procedure code on the claim, then it must be returned in the SVC06-7 element.

The wording was expanded in 5010 to make it more understandable, but there is no change in requirement. Whether receiving 4010A1 or 5010 837 the data requirements are the same in both the 4010A1 and 5010 835. Remediation is not a factor for this data requirement. Note – in the 4010 Professional and Dental claim, the procedure description was reported in the 2400 NTE segment.
Submission 7/19/2010
Status Date 9/20/2010
Status F - Final
Primary References
Document 005010X221
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