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Back  RFI # 1670: HRA/HSA Payments in 835

Formal vs. Informal Help Informal Formal

Submitter

Jan Klimper

Description

How should HRA or HSA payments be identified in the 5010 835? RFI #642 provides a link to 3 different ways to convey this message. This link no longer works. I would like to understand all 3 options - can you please repost?

Submitter Assigned Keywords

HRA HSA 835 ERA

Response

There are currently 3 models in the industry for reporting patient Spending Account payments.

In the ‘All in One Model’, the Health Plan is the Spending Account manager. A single 835/EFT is used to report both the healthcare insurance payment and the Spending Account payment in the same CLP. The Spending Account payment is reported using CARC 187 (Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)).

CLP*ABC*1*200*180**12~
CAS*PR*1*140**187*-140~
CAS*CO*45*20~


In the ‘Two in One Model’, the payments are issued separately because the Health Plan does not manage the Spending Account. The Health Plan payment is generated with the patient portion in CLP05. Remark Code N367 (Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.) should be used to indicate subsequent payment by a Spending Account may be forthcoming.

The financial institution that manages the Spending Account will issue payment for the patient portion with limited claim detail.

CLP*ABC*1*200*40*140*12~
CAS*PR*1*140~
CAS*CO*45*20~
MOA***N367


In the ‘COB Model’, the Health Plan is also acting as the Spending Account bank, so interaction with the actual bank is transparent. The Health Plan sends both the healthcare payment and the Spending Account payment in 2 separate 835s/EFTs, within a close proximity of time (same day or within a few days of each other). The Health Plan 835 should use Remark Codes N367, N509 (Alert: A current inquiry shows the member’s Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.), N510 (Alert: A current inquiry shows the member’s Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.) or N511 (Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time.) (as applicable) to indicate subsequent payment may be forthcoming. In the Spending Account Payment 835, the CLP02 (Claim Status) must equal 2 – Processed as Secondary and Remark code N520 (Alert: Payment made from a Consumer Spending Account.) can be used to further indicate payment was made from a Spending Account.

Healthcare payment - Primary
CLP*ABC123*1*200*50*130*12*123~
CAS*CO*45*20~
CAS*PR*1*130~
MOA***N509

Spending Account payment - Secondary
CLP*ABC123*2*200*130**12*123~
CAS*CO*23*70~
MOA***N520
Submission 8/24/2012
Status Date 10/16/2012
Status F - Final
Primary References
Document 005010X221
Section1