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Back  RFI # 1941: 835 Predeternation with PatRes

Formal vs. Informal Help Informal Formal

Submitter

Joyce Petrucci

Description

How to send a valid 835 Predetermination when the anticipated services upon completion of services, is Zero with the patient responsibility for the full amount.
The 835 was sent as follows:

LX*4~
CLP*124702136*25*2302*0*2302*12*2014154167039*11*1~
CAS*OA*101*0~
.
.
SVC*AD>D6059*2302*0**1~
CAS*PR*204*2302*1~

Technically, the only problem is that the first CAS segment will be NOT Valid, because the CAS03 cannot be equal to Zero. Yet the OA 101 is stating the amount that would be covered (Predetermination: anticipated payment upon completion of services or claim adjudication.) Yet when there is to be no payment how do we follow the rules of the Pre-determination (using CLP02 = 25 and OA 101 ) as advised without breaking rules?

Otherwise, this 835 meets the requirements of the TR3.

Submitter Assigned Keywords

835 Predetermination

Response

Guide section 1.10.2.7 (Predetermination of Benefits) states "The future payment is expressed as an adjustment in one of the CAS segments. Use a Claim Adjustment Group code of OA, (other adjustment), and a Claim Adjustment Reason Code of 101, (predetermination, anticipated payment upon completion of services.') " It also states "A predetermination is identified by Claim Status Code value 25, "predetermination pricing only -- no payment," in CLP02.

Therefore, a predetermination claim is identified by the CLP02 value of 25. The usage of CARC 101 only applies when there is a future payment to be reported, and is not in conflict with the requirement to not report zero adjustments. Since there is no future payment, there is no CAS with CAS02=101. The 835 should look like:

LX*4~
CLP*124702136*25*2302*0*2302*12*2014154167039*11*1~
.
.
SVC*AD>D6059*2302*0**1~
CAS*PR*204*2302*1~
Submission 6/16/2014
Status Date 7/10/2014
Status F - Final
Primary References
Document 005010X221
Section1.10.2.7
Page28