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Formal vs. Informal Help Informal Formal


Kim Janson


Are payers required to use the 835 HIPAA standard transaction to notify providers of adjudication changes that result in take backs/refunds, or is this allowed to be reported on a proprietary report? We have a payer that is using standard remit codes on a proprietary refund report and we are uncertain whether this information should be coming on the 835 as well.

Submitter Assigned Keywords

refund takeback


This issue is addressed in guide 005010X221 in section - Claim Overpayment Recovery. Health plans may use a letter to notify a provider of a change in adjudication that results in an overpayment recovery. The letter must include the details of the adjudication changes, the amount due, as well as a financial control number. The same section identifies how to perform the same function using the Reversal and Correction process identified in section

Additional requirements are provided that include acknowledgment of checks sent by providers.

A health plan may use either the 835 or a letter process to provide overpayment notification to providers. The guide makes no mention of a propriatary report in those terms. The guide statement reads "A health plan may choose to not recoup the funds immediately and use a manual reporting process to the provider. This process involves sending a letter identifying the claim, the changes to the adjudication, the balance due to the health plan and a statement identifying how long (or if) the provider has to remit the balance." As long as the report provides the information identified, and complies with the other requirements in the section, the report can be construed to comply with the intent of the guide.
Submission 5/28/2013
Status Date 6/21/2013
Status F - Final
Primary References
Document 005010X221