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Back  RFI # 184: 835 Capitation Encounters

Formal vs. Informal Help Informal Formal

Submitter

Lemakis Peter

Description

If a provider sends us a claim, and it turns out all of the services
sent are considered capitated by us, aren't we also obligated to
respond to this encounter claim in an 835?

The Implementation Guide does not mention the word encounter. We know
encounter data may not always be covered by HIPAA if for reporting purposes, but our providers may be submitting a claim for payment (not
reporting) purposes, and we determine it is actually a capitated service. Any clarification you provide will be greatly appreciated.

Submitter Assigned Keywords

835 Capitation Encounters

Response

This issue is not specifically addressed in guide 004010X091. The guide does not distinguish between fee for service claims and encounter only claims. The closest applicable instructions are in section 2.2.1.1 where reporting of services is required for professional claims

Recommendation

More recent guides provide explicit instructions for reporting encounters. Guide 004050X124 was published in March of 2003. Section 2.2.19 (Reporting Encounters in the 835) provides explicit instructions. To paraphrase, when both the payer and the provider identify the claim as encounter only, that claim does not need to be reported in the 835. The guide is available from www.WPC-EDI.com to see the whole section.
Submission 1/31/2005
Status Date 3/16/2005
Status F - Final
Primary References
Document 004010X091
Section2
Page19
Set ID2.2.1
Table2
Loop2110
Segment Position070
Segment IDCAS
Element Position03
Industry NameBalancing for Capitated Svcs.