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Back  RFI # 1407: 835 Class of Contract REF CE

Formal vs. Informal Help Informal Formal

Submitter

Jan Klimper

Description

We are currently sending Other Related Claim Identification Class of Contract REF*CE segment as REF*CE*PARTICIPATING PROVIDER or REF*CE*NON PARTICIPATING, whether or not a CAS*CO is present. (Example: Claim pays in full - we still send this segment to identify if processed as PAR or NON-PAR.) Is this an acceptable usage of this segment in 5010?

Submitter Assigned Keywords

CE Class of Contract Other Related Claim Identification 835 5010

Response

The purpose of the OTHER CLAIM RELATED IDENTIFICATION segment is to provide additional information on adjudication of the claim in the associated CLP segment. Whether or not this adjudication results in an adjustment to the paid amount versus the billed amount based on a contractual obligation (CAS*CO), the provider's standing as PARTICIPATING or NON PARTICIPATING is relevant to the adjudication and therefore valid for use with REF*CE under the 5010 guide.
Submission 9/15/2011
Status Date 11/16/2011
Status F - Final
Primary References
Document 005010X221
Section2.4
Page169
Loop2100