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Back  RFI # 1809: 835/820 combined useage

Formal vs. Informal Help Informal Formal

Submitter

Carol Ito

Description

Is it appropriate to use the 835 to make payment for capitation payments and use the 820 to report the detail information for the people?

Our system currently makes capitation payments using the 835 (payments shown in the PLB segment).

It uses the 820 to report the individuals and their associated capitation payment and/or adjustments.

The dollars reported at the detail in the 820 are totaled. That total is reported in the BPR02. The BPR04 is shown as "NON" for "Non-Payment Data".

All 're-association" for payment is included in the 835 BPR segment.

Submitter Assigned Keywords

835 820 useage combined

Response

For the purposes of this response:

Capitation payment is a payment from a health plan to a provider that is based upon the number of covered lives that the provider is assigned by the managed care health plan.

Premium payment is a payment from an employer or a originating health plan to a destination health plan to cover individuals in the benefits of the destination health plan or for the destination health plan to manage the benefits administration of the originating health plan.

It is appropriate to use the 835 to make capitation payments. This is described in guide 005010X221 in section 1.10.2.10 (Capitation and Related Payments or Adjustments). That section also states "The 835 does not contain the capitation details or membership roster. Use an associated Eligibility and Benefits Notification Transaction set (271) to communicate these details."

The 820 guide referenced with this RFI is 005010X218, where section 1.1, states "The Payroll Deduction and Other Group Premium Payment....for the purpose of reporting payroll deducted and other group premiums." It is not appropriate to use this guide to report the people (capitation roster) as that is not consistent with the stated purpose. A capitation list is not a premium payment.

The recommended transaction to use for a capitation roster is the ASC X12 Eligibility, Coverage or Benefit Information (271) transaction. Guide 004010X040 (271 Unsolicited Health Care Eligibility/Benefit Roster), which covers this business is published and available. A newer version of the guide is in development at this time.

If you are referring to a preminum payment being made to a health plan or MCO under a capitated agreement, then the 820 is used for both the payment and reporting of the individuals.
Submission 6/4/2013
Status Date 7/23/2013
Status F - Final
Primary References
Document 005010X218
Section1.1