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Back  RFI # 1645: Reporting Capitated Payments

Formal vs. Informal Help Informal Formal


Doreen Espinoza


Payers are allowed to send non-payment ERAs to a providers as defined in section of the 835 TR3. The instructions provided address a capitation arrangement where the payer pays a specified amount of money per member per month.
There is a different type of arrangement where the payer prepays a bulk payment, with specific allowed amounts that can be spent per person. The allowed amount is used up claim by claim until the funds run out for that person.
Providers are not able to auto post the captitated payments as the payer is treating the payments as though they were in a capitation arrangement. The Payer is using a CO25 to discount to a fee schedule and then a CO24 to take the payment away. In order for the capitated payment to work the provider wants the payment to be reflected at the line level and the dollars to be adjusted at the PLB level.
We request that X12 provide guidance for reporting the capitated payment in the 835.


Not all Zero remits are due to Capitation. The situation described sounds more like section Advanced Payments and Reconciliation where monies are given in advance and then claims are adjudicated against the funds already paid. When this occurs it is imperative that the claims that are paid reflect that they are paid, in order for the providers to accurately post to the patients account.

When a claim is adjudicated and reported on the 835, the claim must reflect the payment and any adjustments while the PLB is used to reflect the money from the advanced payment that has been taken in that RA.

The arrangement between the payer and the provider to do advance payments should in no way hinder the ability for the provider to post claim details to the patient accounts.

The example in the section is quite complex to simply reflect this process see the following simple example. All segments are not shown for simplicity and space limitations.

RA1: Providing the advanced payment

RA2: Two claims are adjudicated against the advance payment


We recommend for this situation that the rules established in Section be used.
Submission 7/25/2012
Status Date 9/18/2012
Status F - Final
Primary References
Document 005010X221
Set ID835