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Back  RFI # 1921: Capitation payments 835-PCMH

Formal vs. Informal Help Informal Formal


Marcia Henderson


We have a Patient Centered Medical Home (PCMH) project. Our physicians receive a payment of $X.00 per patient per month for those patients in the PCMH. Currently payment information for this payment fee is being issued separately outside of the 835 process. We are in the process of moving this payment into the 835/EFT process. Must the total amount of capitation be returned in the PLB segment with the appropriate qualifier for Capitation payment? Or, can each patients payment for $x.00 be returned as a separate claim on the 835. These claims would not be submitted by the provider but would be claims entered into the payers claim system by the payer.


This issue is explicitly addressed in the 005010X221A1, Section Capitation payments and capitation related adjustments are reported in the PLB Segment in elements PLB04, 06, 08, 10, 12, and 14. The 835 does not contain the capitation detail or membership roster. The actual membership roster and capitation details are reported outside of the 835 transaction. Based on these requirements, the amount of the capitation payment(s) would be reported in the PLB segment. A re-association key from the roster would be used to tie the roster and payment. That key can relate to the roster as a whole or individuals within the roster, allowing for member specific payment. It would not be compliant with the transaction to report any capitation payments in the 2100 (claim) loop on the 835.

PLB03, 05, 07, 09, 11, and 13 are used to provide the applicable Adjustment Reason Code and reference number/re-association key associated with the capitation payments and adjustments. Multiple PLB segments are used as needed.


A 271 Unsolicited Health Care Eligibility/Benefit Roster transaction (004010X040) may be used to report the membership roster and capitation detail. In the case of a capitation payment related to a member list provided in a 271 transaction, a TRN Segment Trace Number contained in the 271 is provided as a PLB reference number for the appropriate dollar amount.

If the membership roster and capitation detail are provided via other means, the PLB reference number would contain a value that identifies a particular roster/member, so that the provider can re-associate the capitation payment to its corresponding membership roster and per member payment detail.
Submission 4/10/2014
Status Date 6/10/2014
Status F - Final
Primary References
Document 005010X221