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Back  RFI # 185: 835 Capitation+FFS Encounters

Formal vs. Informal Help Informal Formal


Lemakis Peter


If a provider sends us (a health plan) fee-for-service detail lines
and capitated service detail lines on the same claim, and we only respond
in our 835 on the fee-for-service lines, wouldn't that be a HIPAA violation,
or at least a balancing problem?

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 Encounter Capitation Balancing


This issue is specifically addressed in guide 004010X091 in section on page 19. The guide does not distinguish between fee for service services and encounter services. The bullet at the bottom of page 19 reads "If any service detail is reported in a claim payment, all services for the claim payment should be reported."
The intent of the word "should" in this context is to establish an obligation. Reporting only the fee for service lines on a claim payment violates this statement.


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
Set ID835
Segment Position070
Segment IDCAS
Element Position03
Industry NameBalancing for Capitated Svcs.