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Back  RFI # 2048: CAGC CO with Coinsurance

Formal vs. Informal Help Informal Formal

Submitter

mintz harvey

Description

The 5010 TR3s for the 835 (at 1.10.2.4) and 837 (at 1.4.1.3) discuss Group Code and CARC usage. There is no explicit statement that the common CARCs that are used to report Patient Responsibility amounts, 1, 2, and 3, must be sent under Group Code "PR", although the guidance for Group Code "CO" would seem to prohibit sending them under "CO". We are receiving large numbers of secondary claims with Group Code "CO" and CARC 2. CARCs 1 and 3 are also being seen with "CO". Is this practice compliant with the guide?

Submitter Assigned Keywords

CAGC, Patient Responsibility, Contractual Obligations

Response

While guide 005010X221A1 (835) makes no explicit statement about usage of specific Claim Adjustment Group Codes (CAGC) with CARCs 1, 2 or 3, there is an inherent expectation that the contents of the 835 accurately represent the claim adjudication. Any CAGC must be used consistent with its meaning and guide instructions. CAGC CO must only be used when the guide direction is applicable, as identified in section 1.10.2.4 "2 - Is the amount adjusted not the patient's responsibility under any circumstances due to either a contractual obligation between the provider and the payer or a regulatory requirement? Use code CO - Contractual Obligation." that section also states "1 - Is the amount adjusted in this segment the patient's responsibility? Use code PR - Patient Responsibility."

In addition, the section states "The Claim Adjustment Group Codes are evaluated according to the following order:". As a result, # 1 above would be evaluated before # 2. If the patient is responsible for the amount of the adjustment related to any specific CARC, then code PR must be used.

The referenced section (1.4.1.3) of the claim guides (005010X222A1, 223A2 and 224A2) does associate CARCs 1, 2 and 3 with CAGC PR, however, the statement before the related listing reads "In most instances..." and the reference is to provider crosswalking from paper proprietary codes to the standard codes. As a result, it has no nearing bearing on the requirement in the 835.
Submission 5/8/2015
Status Date 6/23/2015
Status F - Final
Primary References
Document 005010X221
Section1.10.2.4
Page22
Set ID835
Table2
Loop2100
Segment Position0200
Segment IDCAS
Element Position01
Industry NameClaim Adjustment Group Code
Code ValueCO