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Back  RFI # 223: REF*6R service line adjudicat.

Formal vs. Informal Help Informal Formal

Submitter

Dyan Anderson

Description

In reviewing the draft 5010 837I & 837P, we see that the 837I has been updated to include a REF*6R segmt for line item control# in which Payers are required to return this # in the 835 if the provider sends it to them in the 837 and adjud. is based upon the line item detail. The 4010A1 837I does not have any "link" to a specific revenue line unless bundling or unbundling occurs based on 2.2.6 of the 835 IG & 1.4.3 of the 837I IG. Since v4010A1 837I does not contain REF*6R, only a LX line counter, there is no perceived requirement for the payer to send the LX # back in the 835 at the service level if any service level adjud is reported in the 835. Is the payer required to send the REF*6R to identify the service line# of the 837I for which ANY service line adjud. occurred even though bundling or unbundling did not occur?

Submitter Assigned Keywords

serviceline REF*6R 835

Response

This is explicitly addressed in guides o04010X091 and 004010X096 in multiple
locations. In the 835, the Provider Control Number in the REF*6R states "This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes, if submitted on the claim this must be returned on remittance advice. In the 837I, "The LX functions as a line counter." The 837I does not contain a Line Item Control Number. Section 2.2.11 of the 835 guide states related to splitting a claim "If the original claim did not contain a specific line item control number for the service lines, the line item sequence number (LX01) from the original claim should be used in the 835 REF segment instead."

As a result, there is no requirement to pass any LX01 value from an 837I in an 835 unless claim splitting has taken place.
Submission 3/22/2005
Status Date 3/31/2005
Status F - Final
Primary References
Document 004010X096A1
Section1.4.3
Page22
Set ID004010