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Back  RFI # 1741: Reprocessed Claims on an 835

Formal vs. Informal Help Informal Formal

Submitter

Dora Lambert

Description

How should the following claim processing be reported on the second 835 for this scenario?

Initial claim is denied. Applicable CAS segments and amounts are reported on the initial 835. Two weeks later, the payer reprocesses the claim to approved/paid.

The payer is reporting the denial on the initial 835 and an approved claim on the follow up 835.

The 5010 835, section 1.10.2.8, Reversals and Corrections, indicates when claim adjudication results have been modified from previous reporting, the method for revision is to reverse the entire claim and resend the modified data. Also in this section, under Reversal Method, it says to reverse the original payment, restoring the patient accounting system to the pre-posting balance for this patient.

If reversing the original payment does not restore the patient accounting system to the pre-posting balance because there is no balance to restore, can the payer report this scenario as described in the 3rd paragraph above?

Submitter Assigned Keywords

Reprocessed Claims

Response

The 5010 835, section 1.10.2.8, Reversals and Corrections, indicates when claim adjudication results have been modified from previous reporting, the method for revision is to reverse the entire claim and resend the modified data. This situation is no different due to the fact that the original claim was denied. The details that were posted into the patient accounting system still need to be reversed out of the Practice managment system to remove all the details that were posted. The correction claim will then post the new and accurate claim payment.

It is not premisable for "The payer to report the denial on the initial 835 and an approved claim on the follow up 835." The instructions in 1.10.2.8 must be followed when the claim adjudication results have been modified from a previous reporting regardless of the reason for the modification.
Submission 1/29/2013
Status Date 3/13/2013
Status F - Final
Primary References
Document 005010X221
Section1.10.2.8
Page29
Set ID835