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Back  RFI # 1656: Primary Payers' Impact

Formal vs. Informal Help Informal Formal

Submitter

Dan Voss

Description

ASC X12 005010X221 section 1.10.2.13 seems to explicitly state that the "impact" of the primary payer's adjudication is to be reported in a CAS segment as an OA-23.

Based on the Business Scenarios in the TR3, it appears that the intention of the specification is that the impact of the primary payers' adjudication is reported as OA-23, even in cases where the secondary payer's adjudication process is not directly affected by the primary payer adjudication. The scenario listed in 3.3.3 seems to show a situation where the secondary payer’s adjudication was not directly affected by the primary payer’s payment and contractual adjustments, however the ‘impact’ of the primary payer’s adjudication is still reported as OA-23.

Are secondary payers always required to report the combination of the primary payers’ payments and contractual adjustments? Is any group code/adjustment reason combination other than OA-23 allowed when reporting the primary payer's payments and adjustments?

Submitter Assigned Keywords

835 secondary impact CAS

Response

ASC X12 005010X221 section 1.10.2.13 does state that the "impact" of the primary payer's adjudication is to be reported in a CAS segment as an OA-23, and that is the only appropriate code/adjustment reason combination. With that said, however, secondary payers are not always required to report the combination of the primary payer’s payment and contractual adjustments since not all payers take into account the primary payer's provider write-off. And if they do, the impact is not automatically the sum of the prior payer’s payments and contractual adjustments. In scenario 3.3.3, the secondary paid $516.00 less because the primary payer paid it. That does constitute an impact.
Submission 8/6/2012
Status Date 10/2/2012
Status F - Final
Primary References
Document 005010X221
Section1.10.2
Set ID835
Table2
Loop2100
Segment IDCAS