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Back  RFI # 174: proper use of prior payments

Formal vs. Informal Help Informal Formal

Submitter

Gladys Jones

Description

question on presentation of prior payments on a professional payment. Which of the following are a correct presentation?

CLP*A2345*2*60*10*0*hm~
CAS*OA*23*50~
SVC*hc:12345*40*40*hc:12345~
SVC*hc:23456*20*20*hc:23456~

or
CLP*A2345*2*60*10*0*hm~
SVC*hc:12345*40*0*hc:12345~
CAS*OA*23*40~
SVC*hc:23456*20*10*hc:23456~
CAS*OA*23*10~

See 4010 version and 4050 for guidance.

Response

This issue is not explicitly addressed in the 004010X091 guide. The recommendation below is no longer valid. HIR 626 is the current recommendation. CARC 23 has been revised to reflect the impact of primary's adjudication upon the secondary. The impact may be up to the actual amount of the primary payment(s) plus contractual adjustment(s).

Recommendation

Since service detail is provided, we assume that the service is the adjudication level for this claim. For that reason, the adjustment detail should be provided at the service level as shown in your second example. We also suggest looking at the 004050X124 guide section 2.2.13 on secondary payments. That instructs the payer to adjust the claim for most reductions as if primary before using Claim Adjustment Reason code 23. As presented in your example, the secondary payer would be allowing payment in full for both services.
Submission 1/7/2005
Status Date 6/17/2008
Status F - Final
Primary References
Document 004010X91A1
Section090
Page148
Set IDcas