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Back  RFI # 1573: 5010 835 CARC 27 on Reversal

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Submitter

Jan Klimper

Description

A claim is originally denied with CARC 27 and a Coverage Expiration Date is returned in the 835.

Later, membership is updated and the claim is adjusted to pay.

The reversal record returned the original CARC 27, but we no longer have a coverage termination date to return since membership records are updated.

Does this follow the rules of the TR3?

Submitter Assigned Keywords

835 5010 CARC 27 Reversal Coverage Termination Date

Response

This is explicitly addressed in guide 005010X221. Section 1.10.28 (Reversals and Corrections) doesn't include any requirement related to the Coverage Exiration Date DTM segment in the 2100 loop. The situational rule on the Coverage Expiration Date DTM segment states "Required when payment is denied because of expiration of coverage. If not required by this implementation guide, do not send." Since the reversal of a previous adjudication (2100 Loop CLP02 value 22) that used Claim Adjustment Reason Code 27 (Expenses incurred after coverage terminated) is not itself denying payment due to expiration of coverage, the situation in the rule is not met and the 2100 loop Coverage Expiration Date DTM segment must not be sent.



Therefore, not sending the Coverage Expiration Date DTM segment in this scenario does follow the rules of the TR3.
Submission 4/25/2012
Status Date 6/18/2012
Status F - Final
Primary References
Document 005010X221
Section1.1
Page175