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Back  RFI # 2080: HIX 837 accums information

Formal vs. Informal Help Informal Formal

Submitter

Kim Peters

Description

In the HIX process there is a need to receive the amount that was applied to deductible, copay, and coinsurance from providers and how the government subsidy amounts are impacted. Is there guidance from the 837 worgroup on how this information is communicated in the 837 at the exchange level?

Submitter Assigned Keywords

HIX accums government subsidy

Response

The reporting of claims already adjudicated is accommodated by the Post Adjudicated Claims Data Reporting (PACDR) TR3s, 837 Institutional X299 and 837 Professional X298. The Health Care Claim TR3s, 837 Institutional X223A2 and 837 Professional X222A1, do not accommodate reporting adjudication information except in the case of secondary or subsequent claims, where prior adjudication information is accommodated.

The PACDR TR3s convey deductible, coinsurance and co-payment amounts in the CAS segment. The codes used in the CAS segment, Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) are external to the ASC X12 standard and any additional code needs to differentiate e.g. types of deductible, would be submitted to the appropriate code maintenance committee.

There is currently no essential health benefits indicator and no member cost sharing level in the PACDR TR3s. Please submit a request with detailed business requirements for the essential health benefits indicator and member cost sharing level to modify a future version of the Post Adjudicated Claims Data Reporting (PACDR) TR3s, 837 Institutional and 837 Professional, through the online TR3 Maintenance Request tool at: http://changerequest.x12.org/
Submission 8/10/2015
Status Date 10/5/2015
Status F - Final
Primary References
Document 005010X222
Section2300