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Back  RFI # 307: Posting Coins and Ded -835

Formal vs. Informal Help Informal Formal

Submitter

Sarah Hataway

Description

In the past, pre-HIPAA, providers received Medicare Coinsurance and Deductible amounts on the paper EOP. Alabama Medicaid does not pay the Medicare coinsurance or deductible amounts, but has its own internal formula to determine the paid amount on a cross-over claim. I am trying to determine how to add this information on the 835.

Examples:
Submitted on Claim to AL Medicaid
Billed Amount 213
Medicare Coinsurance 25
Medicare Deductible 25
Medicaid Paid Amount 97.26

Currently returned on AL 835
CLP03 Billed Amount 213
CLP04 Paid Amount 97.26
CAS03 Claim Adjustment - claim adjustment reason code of 42 115.74
Modified 835 with coins/ded.
CLP03 Billed Amount 213
CLP04 Paid Amount 97.26
CAS03 Claim Adjustment - claim adjustment reason code of 42 65.74
CAS06 Claim Adjustment - claim adjustment reason code of 1 $25
CAS09 Claim Adjustment - claim adjustment reason code of 2 $25

Note - the patient owes no money.

Response

This issue is explicitly addressed in guide 004010X091. Section 2.2.4 states that the CAS segment provides "...the reasons, amounts, and quantities of any adjustments that the payer made...". Since the deductible and co-insurance referenced are Medicare's and not adjustments by the current payer (Medicaid), they do not get reported in the 835. As payer of last resort and with a legel requirement that the provider accept the payment as payment in full, the code that should be used for the difference between the original charge and the Medicaid allowed amount is 45, not 42, with a Claim Adjustment Group code of CO (contractual Obligation) per the same section.
Submission 8/12/2005
Status Date 8/19/2005
Status F - Final
Primary References
Document 004010X091A1
Section2.2.1
Page95
Set ID835
Table3
Loop2100
Segment IDCAS
Industry NameMonetary Amounts