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Back  RFI # 2157: Contracted funding CARC 139

Formal vs. Informal Help Informal Formal

Submitter

Heather Morgan

Description

What is the proper way to adjust payment when provider is also the plan sponsor, the patient is their employee (or on the employee's plan), and there is an agreement to suppress payment?
We currently send 0 paid in the CLP*04 and adjust the amount we *would have* paid with a claim level CAS using PI*139.
A provider is questioning our process. They say there are other payers that send a dollar amount in the CLP*04. I am unable to find information specific to this topic, with the exception of RFI 2022, which does not appear to answer our question.

Submitter Assigned Keywords

139 contracted funding agreement draft suppression

Response

The 005010X221A1 guide explicitly states in the note for the CLP04 “Use this monetary amount for the amount paid for this claim.” Therefore, CLP04 must be "0" since there is no payment involved. Section 1.10.2.1 also requires that the claim and services balance.

The semantic note and TR3 notes on SVC03 explicitly state that SVC03 is the Service Line Paid Amount. Since no payment is being made, this must also be "0", when service lines are present.

CARC 139 (meaning "Contracted funding agreement - Subscriber is employed by the provider of services.") is the appropriate code to achieve balanced services and claim. The CAS segment at the appropriate level - 2110 loop when services are present and 2100 loop when the 2110 loop is not present - then uses CARC 139 with the appropriate dollar amount to balance to a zero payment. Since by definition this is a "Contracted funding agreement", the appropriate Claim Adjustment Group Code is CO (meaning Contractual Obligation")."

When services are reported on a claim, the service needs to be reporting all of the related information in order to facilitate understanding and automation by the provider. Reporting an SVC03 value that represents the total submitted service charge when that amount is not in fact being paid due to reporting of all adjustments at the claim level is not compliant with the guide.
Submission 6/15/2016
Status Date 8/24/2016
Status F - Final
Primary References
Document 005010X221
SectionDetail
Page129
Set ID835
Table2
Loop2100
Segment Position0200
Segment IDCAS
Industry NameCAS - CLAIM ADJUSTMENT
Code Value139