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Back  RFI # 358: 835 CAS segments

Formal vs. Informal Help Informal Formal

Submitter

Dyan Anderson

Description

Can payers send only service level CAS segments in 835 transaction and not report any claim level adjustment (adj) CAS segments? If claim and service level CASs are reported, should the total of both be used for overall claim adj? Based on the balancing section 2.2.1.2 and 2.2.4, a service level adj should never be included in a claim level adj, correct? or service level balances with claim level? For ex: a claim for $500 is paid $200. If have claim level CAS of $150 -CAS*PR and $150 is applied to CAS*CO, can service line adj be reported for two service lines: LX1 for $250 paid $100 and CAS*CO = $75 and CAS*PR = $75 and LX2 for $250 paid $100 and CAS*CO = $75 and CAS*PR = $75 so total CAS*PR of $150 for both service line total the claim level CAS*PR of $150 and CAS*CO of $150 total the claim level CAS*CO of $150? or the service level adj are not included and do not balance to the claim payments and adjustments?

Submitter Assigned Keywords

835 CAS segments claim versus service level balancing

Response

This issue is explicitly addressed in guide 004010X091A1. Section 2.2.1.2, page 21 states "When the Service Payment Information loop is present, adjustments are reported in either the Claim Adjustment or the Service Adjustment Segments but not in both. For example, if a $100 deductible adjustment is taken at the service level, do not repeat that deductible at the claim level. It is preferred that the adjustment be shown at the service level when possible."

Also, the different balancing algorithms explicitly define which adjustments are used at each balancing level. Re-read this carefully. Service adjustments ARE included in the claim balancing. Including a specific adjustment at the service and claim level will cause the 835 to be out of balance.
Submission 11/14/2005
Status Date 11/22/2005
Status F - Final
Primary References
Document 004010X091
Section2.2.1.1
Page20
Set ID835
Segment IDCAS