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Back  RFI # 2022: SVC03 vs CAS CO 139

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

We process claims for a hospital’s employees for benefits only and need to show what we would have reimbursed. 835 will show benefit appl CAS adjustments (denials or adjustments). Are we required to show CO 139 at each line to show what we would have paid ? or can we show what we would have paid in SVC03 for the lines we alow and then do a claim level CAS for CO 139 to offset those SVC03 amounts? SVC03 is to report prov paid amounts but we are not paying them. Here are two diff options: what is correct? Remembering that any given line may not be reimbursable as well if more than one line.
CLP*xxxxx*1*12634.03*0*384.3*12*xxxxx*13*1~
CAS*CO*139*3458.7~
SVC*NU:0240*12634.03*3458.7**1**0~
DTM*472*20150121~
CAS*CO*45*8791.03~
CAS*PR*3*384.3~
AMT*B6*3843~
Or
CLP*xxxx*1*12634.03*0*384.3*12*xxxx*13*1~
SVC*NU:0240*12634.03* 0**1**0~
DTM*472*20150121~
CAS*CO*45*8791.03~
CAS*PR*3*384.3~
CAS*CO*139*3458.70~
AMT*B6*3843~

Submitter Assigned Keywords

SVC03 CARC 139

Response

The 005010X221A1 TR3 in the 2110 SVC Segment Situational Rule states 'Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem).' Additionally, the 2110 CAS Segment Situational Rule states 'Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02).

If service level pricing is applicable and must be reported in the 2110 Loop per the TR3 requirements and the service payment (SVC03) does not equal the service charge (SVC02), as indicated in this business situation, then the 2110 CAS segment is required to report the service level adjustments, including CO 139. Consequently the second example reflecting the CO 139 adjustment for each applicable service at the Service Level 2110 Loop is consistent with the TR3 requirements. However if 2 'CO' adjustments are applicable to the same service, they would be reported in a single CAS segment, rather than 2 separate CAS segments, per Section 1.10.2.4 - Claim Adjustment Information and Service Adjustment Information Segment Theory of the TR3.

Related RFIs - 618, 1034, 1950
Submission 3/3/2015
Status Date 4/2/2015
Status F - Final
Primary References
Document 005010X221A1
Sectiondetail
Page186
Set ID835
Loop2100
Segment Position200
Segment IDCAS
Element Position02
Industry NameClaim adjustment
External Code List139
Code Value139
Secondary References
RFI ID 2500
Document 005010x221a1
SectionDetail
Page186
Set ID835
Loop2110
Segment Position700
Segment IDsvc
Element Position03
Industry NameMonetary amount