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Back  RFI # 1436: Outlier payments and CAS seg

Formal vs. Informal Help Informal Formal


Bobbi Matt


005010X221 835 file
Receiving in an ERA file with the following data In the 2100 CLP loop we get total chg 209064.53 with a CLP04 of 39674.53. The 2100 CAS segment sent is a CO45 with 169389.67, what was expected would be total adjustments of 173884.76 If this is accurate then I would expect to get from the payer the CAS Segment back as a CO45 169389.67 and then a second CAS segment with the CO69 or CO70 with a -4495.09 which would then total to the true adjustment on the account of 173884.76.
Would this be correct in how we would expect to receive the outlier payment and associated CAS segments (adjustments to be taken on the account). If not how should an outlier payment be sent and how is that then represented in the 2100 CAS segments?

Submitter Assigned Keywords

835 outlier MIA


Outlier payments get reported in the 835 as increases to the payment over and above the allowed amount. The proper process is to adjust the claim or service to the allowed amount first, and then post the outlier adjustment (69 or 70, as appropriate) to increase the payment by the amount of the outlier. Any remaining patient responsibility amounts would then be reported to arrive at the actual health plan payment.

For example, a primary PPO claim is received and adjudicated. The submitted charge is $10,000. The normal allowed amount is $6,000. This results in an adjustment with CARC 45 for 4000. A cost outlier applies resulting in an additional payment of $500. CARC 70 (meaning "Cost outlier - Adjustment to compensate for additional costs.") is used to identify that adjustment reason, with a dollar amount of -500. This gets reported as a negative amount in the CAS segment, since the CAS amounts are subtracted from the submitted charge. There is no remaining patient responsibility, so the total payment for this claim is $6,500.

The related segments would look like:

CLP*Provider Claim Number*1*10000*6500**12*Payer Claim Number~
Submission 10/19/2011
Status Date 12/8/2011
Status F - Final
Primary References
Document 005010X221
Segment Position330
Segment IDMIA
Element Position02
Secondary References
RFI ID 1886
Document 005010X221
Set ID835
Segment Position0200
Segment IDCAS
Element Position03