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Back  RFI # 396: Zero patient responsibility

Formal vs. Informal Help Informal Formal

Submitter

Julia Dunicheva

Description

CLP05 in 835 transaction has a note that it must be entered if greater than zero and should have supporting adjustments in CAS segment.

Is zero a valid value for CLP05 element ?
If yes, should it have supporting adjustments in CAS segment ? or segment CAS can be omitted in this case.

Submitter Assigned Keywords

835 patient responsibility amount

Response

This issue is explicitly addressed in guide 004010X091. Section A.1.3.1.2 states that, for R type data elements like CLP05, leading and trailing zeroes should be suppressed unless necessary to meet minimum length requirements or to indicate precision. Since neither applies here, sending a zero in CLP05 is not appropriate. Requirements for usage of the CAS segment are not based only, or primarily, upon the note on CLP05. The CAS requirements must be evaluated based upon the requirements established in other sections, like the CAS segments themselves and sections 2.2.1 (Balancing), 2.2.6 (Procedure Code Bundling and Unbundling) and 2.2.8 (Reversals and Corrections). As stated in CAS segment notes, the CAS segment is used to report “adjustments that cause the amount paid to differ from the amount originally charged.” Usage of the CAS segment were there is not a difference is also not appropriate.
Submission 3/28/2006
Status Date 4/4/2006
Status F - Final
Primary References
Document 004010X091
Section3.1
Page91
Set ID835
Loop2100
Segment IDCLP
Element Position05
Industry NamePatient Responsibility Amount