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Back  RFI # 387: Patient Responsibility and COB

Formal vs. Informal Help Informal Formal


Pam Cottrell


We are producing 835s that I think need some tweaking to make them correct. Like many payers we have situations where prior to applying the amount the other carrier paid it appears that there is patient responsibility (deductible, coinsurance, copay). However once we apply the COB dollars the end result is that the patient owes nothing because the dollars were covered by the COB amount or we paid it out of previously accumulated savings.
Here is an example of our current CAS segments:
The PR*1 is used to show that it went towards satisfying the deductible and the 22 is used to offset the patient responsibility. In cases like these should we just not have a CAS*PR segment?

Submitter Assigned Keywords

835 CAS PR COB patient responsibility


There has been much confusion on how to report secondary payments in the 4010A1 835.

CARC 23 was modified, at the request of the workgroup, so that it applies to the dollar amount that impacted the secondary payment, e.g., primary contractual adjustments and payments. Following your example, the patient did not owe the provider any additional money because the primary payer paid the services in full. The impact amount would be $10. There is no need to tell the provider that the patient responsibility amount was offset by the primary payment. The CAS for SVC*HC:99213*10*0~ should read: CAS*OA*23*10~, only. The PR CAS should not be used.

The workgroup held a Lunch & Learn session on COB during the June 2005 Trimester Meeting. Please see "Understanding COB Reporting in the 835" which can be found at http://www.wpc-edi.com/docman/Itemid,264/task,view_category/catid,87/order,dmname/ascdesc,ASC/.
Submission 2/14/2006
Status Date 5/1/2006
Status F - Final
Primary References
Document 004010X091A1
Set ID835
Segment Position090
Segment IDCAS