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Back  RFI # 1812: Subscriber Pay 835 reporting

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

When a payer reimburses the member/patient/subscriber - The assumption is the money that was paid to the sub would be reported as a CAS with CARC 100 so the claim or line would balance as nothing would be shown in reimbursement SVC03. The question is what group code should be reported. The tr3 does not advise. In some instances it may be know if the provider colleced the money from the patient up front and in other cases it may not be known - Please advise what the group code would be OA or PR?
Example CHarge is 100, allowance is 75. Provider is not participating The 835 would report PR 45 for $25 and a ?? 100 for $75. what is the group code that would be recommended?

Submitter Assigned Keywords

subscriber Pay

Response

PR is the appropriate Claim Adjustment Group Code (CAGC).

The ASC X12 “Health Care Claim Payment/Advice” Technical Report Type 3 005010X221A does not explicitly address which CAGC is to be used with Claim Adjustment Reason Code (CARC) 100.

The ASC X12 “Code Value Usage in Health Care Claim Payments and Subsequent Claims” Technical Report Type 2 does provide X12’s opinion of which CAGC(s) are appropriate with each CARC. In the case of CARC 100, the only appropriate CAGC is PR – Patient Responsibility.

Recommendation

The 835 patient responsibility amount is not an indication of whether money has or has not already been paid by the patient. It is reporting the total amount that the health plan believes that the provider can receive (past or future) from the patient. At the time of adjudication, there is no way for the health plan to be certain of the total amount that the patient has already paid to the provider. While the original claim should have identified any patient payment, other actions may mean that the original information is no longer accurate.

It is also possible that an 835 would not be generated in all instances. The patient might have paid the provider and then submitted the claim to the health plan for reimbursement. In this case, the provider would not be involved and an 835 might not be created.
Submission 6/17/2013
Status Date 7/19/2013
Status F - Final
Primary References
Document 005010X221
Section2
Page198
Set IDCAS01
Secondary References
RFI ID 2286
Document 005010X221
Section2
Page190
Set IDSVC03