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Back  RFI # 2060: Withdrawal/Void Claim and Resp

Formal vs. Informal Help Informal Formal

Submitter

Jerry Sobotka

Description

There are times when a Provider will realize that they have submitted a claim to a Payer and with retrospect, the Provider determines that the claim should not have been submitted to the Payer. The Provider, having recognized the need to withdraw or void the claim submission, would like to utilize HIPAA transactions to communicate the withdrawal/void to the Payer and receive notification/acknowledgment that the Payer has processed the withdrawal/void request.
Assuming that the Provider will submit the withdrawal/void using the 837 transaction, what is the recommended means of communicating the withdrawal/void?
How should the Payer respond to the Provider regarding the acceptance and processing of the withdrawal/void in the two following scenarios:
1.Assume that the Payer has processed the original claim and communicated the outcome to the Provider. 2.Assume that the Payer has received the original claim, but has not completed processing or communicated the processing outcome to the Provider

Response

For scenario 1, the 835 005010X221A1 explicitly addresses how reporting should occur on a claim that is modified from the original finalized processing results. The method of notification via the 835 is use of the Reversal process defined in Section 1.10.2.8. No Correction claim would be sent since there is no longer 'a claim' as a result of the withdrawal/void.

For scenario 2,. the 835 005010X221A1 is used for reporting finalized claim adjudication results and not claims that are still processing or pending as evidenced by the Loop 2100 CLP02 values. Additionally, according to the 837 transactions withdrawal/void claim submissions require the Payer Claim Control Number of the 'previously adjudicated claim' (Reference the situational rule for the 2300 REF-Payer Claim Control Number). As stated by the rule, the provider should be submitting a replacement or void claim after the original claim has been adjudicated.

If the payer utilizes the Health Care Claim Acknowledgment (277CA) to acknowledge claims via the 837, then the 277CA would reflect acceptance of any withdrawal/void claims being entered in to the payers system for adjudication.

Recommendation

Scenario 1, 'ALERT' RARCs are not required on the reversal claim, but can be added to indicate why a reversal was performed. RARC N693 could be used for this situation.

Scenario 2, payers vary on accepting void claims while the original claim is still processing, assuming the provider is able to submit the Payer Claim Control Number for the original claim. Since the 835 is used to report adjudicated finalized claims, and accepting the withdrawal/void claim while the original claim is still processing essentially results in 'no claim', there would be nothing to report in the 835. Lack of payment or notification of finalized adjudication results could be the only way a provider knows the withdrawal/void was received. If the payer utilizes the Health Care Claim Acknowledgment (277CA) to acknowledge claims via the 837, then the 277CA would have reflected acceptance of the withdrawal/void claim being entered in to the payers system for processing and that may be the only notification the provider receives.
Submission 6/3/2015
Status Date 8/27/2015
Status F - Final
Primary References
Document 005010X221
Section2.4