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Back  RFI # 1733: 835 Reversals and corrections

Formal vs. Informal Help Informal Formal

Submitter

Gale Scott

Description

We are receiving 835 files that contain reversals and corrections to previously paid claims. The original payment was paid at the service line level. The payer is sending the reversal only at the claim level, thus negating the possibility of being able to post it electronicallly since it is for a professional service. They then send the Correction (readjudicated payment) with the full service line detail.

The payer interprets the 5010 TR3, section 1.10.2.8 of the Front Matter as meaning that only the corrected payment must match the level of detail of the original payment. They don't think the requirement to report at the same level of detail applies to the reversal of the original payment.

This practice prevents the electronic posting of the reversal due to no line detail. If this is not corrected we will have to stop all electronic posting of 835 files from this payer.

Is there a requirement to report back a reversal claim at the same level as the original claim was adjudicated?

Submitter Assigned Keywords

reversal correction svc03 professional

Response

Section 1.10.2.8 , paragraph 1 states "If any of the service lines within a claim were communicated as pending in the 835 when making a partial payment, the payer must reverse the original payment and resend the data when paying the pended lines." This indicates applicability of the reversal to the service lines (2110 loop).
Section 1.10.2.8 Reversal Method states "Reverse the original payment, restoring the patient accounting system to the pre-posting balance for this patient." and "All original charge, payment, and adjustment amounts are negated."

The 2nd bullet of the Notes at the end of the section states "The example does not provide service line detail. If the service line detail had been on the original payment, then the reversal must apply the same reversal logic to the claim and service lines."

Therefore, if the original claim payment reported service detail (which is required for professional claims) then the related reversal must also contain service line details and include the detail at that level to allow the provider's system to be restore to the original balance for each service line before the remittance was posted. A reversal claim must report back at the same level as the original claim adjudication was reported.
Submission 1/17/2013
Status Date 2/19/2013
Status F - Final
Primary References
Document 005010X221
Section1.10.2.8