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Back  RFI # 1944: Rev/Corr payer combined claim

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Submitter

Jeanne Kirkpatrick

Description

Need clarification on the correct way to report an 835 rev/corr when during a payer audit (per agreement with hospital) two claims are combined because a readmit date is within 14 days of the 1st admit (does not result in recoupment of dollars, additional payment, or the need for the hospital to rebill a corrected claim). The 835 TR3 and RFI276 state CLP03 is the “submitted” charges from the provider. Since the hospital is not sending a corrected claim is the example below correct?

Ex. 1st admit 12/7/12-12/13/12, charge of 56,087.64; 835 reflects payment of 43,957.22; CO*45*12,130.42. 2nd admit 12/15/12-12/21/12, charge of 18,119.46; 835 reflects payment of 9,384.52; CO*45 *9,526.94.After the claims are combined, the 1st admit 835 is reversed; the corrected 835 reports 56,086.64 charge with a 0 payment. The 2nd admit 835 is then reversed; the corrected 835 combines dates of service; reports charge 18,119.46 (provider submitted) with payment 43,957.22; difference of -25,045.76 reported as a CAS*OA*94.

Submitter Assigned Keywords

835 reversal correction payer audit combined claim

Response

Following the reversal and correction rules as outlined in the front matter section 1.10.2.8, the payer would send an reversal for the first and second claims in the 835. The payer would use the 1st admit claim and correct it to combine, as appropriate, the total charges from each of the claims (1st and readmit claims) as well as adjust the dates of service. The payment and adjustments are then based on the contract.
Submission 6/23/2014
Status Date 11/7/2014
Status F - Final
Primary References
Document 005010X221A1
Section1.10.2.8
Loop2100
Segment IDCLP
Element Position03