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Back  RFI # 319: 835 Adjustment/Reversal

Formal vs. Informal Help Informal Formal

Submitter

Pete Vyzaniaris

Description

I had a question concerning how to handle adjustments within
the file, specifically the correlation between the CLP02 qualifier and the
CAS01 qualifier.
Understanding:
If an adjustment is made on a claim, the 835 CLP02 segment it should have a qualifier of "22" (Reversal of Previous Payment) with an amount in CLP03 and CLP04 fields. In addition to that the CAS01 field should have a qualifier of "CR"(Correction and Reversals) with an amount in the CAS03 field.
Questions:
When there is an adjustment qualifier in the CLP segment, specifically a
CLP02=22 can their be a value in CLP05 field patient responsibility?
When an adjustment is made on the CLP segment with a CLP02 qualifier do the corresponding CAS01 qualifiers must have a value of "CR" or can they have other values like "CO", "OA", "PR"?
Thank you.

Submitter Assigned Keywords

835

Response

This issue is explicitly addressed in guide 004010X091. Section 2.2.8, Reversals and Corrections, states "Reversing the original claim payment is accomplished with code 22, ‘‘reversal of previous payment’’, in CLP02; code CR, ‘‘corrections and reversals’’, in CAS01; and appropriate adjustments." It also states "The reversal does not contain any patient responsibility amount in CLP or a patient responsibility-specific CAS segment."

Therefore, it is not compliant with this guide to have CLP02="22" and any value in CLP05 or a value different than "CR" in CAS01.
Submission 8/31/2005
Status Date 9/2/2005
Status F - Final
Primary References
Document 004010X091
SectionDetails
Page89
Set IDCLP