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Back  RFI # 424: 835 Capitated Services

Formal vs. Informal Help Informal Formal


chip dycio


Please describe in detail how capitated services/claims should be reported on the 835 remittance transaction. Specifically, how should data on the CLP, CAS, PLB, and BPR segments be valued?

Submitter Assigned Keywords

capitation capitated


When paying capitated claims, there are 3 possiblities. 1. A pure encounter claim (submitted as all encounters and the payer agrees) does not need to be reported in the 835. (If payer does not agree, then a response must be sent in the 835.) 2. If a claim was submitted with some encounters and some payable services, the payer must return all services with a charge > $0 and any $0 services IDd as payable during adjudication. Report payment of $0 services by using CARC 94 and a negative dollar amount. Adjustments must also be provided. Any services with a $0 charge and identified as capitated by the payer do not need to be returned. 3. For claims with all charges >$0 (and not identified as all encounters using BHT06 = RP), the payer must return all services. Services that the payer determines are capitated are adjusted to pay $0 using CARC 24. " Since all of these could apply to a specific payer independent of their system processes (to a certain extent the issue is how the claim was submitted).


For more information about reporting encounters, see the version 5010 835 IG (# 005010X221)section, available at www.wpc-edi.com.
Submission 6/28/2006
Status Date 8/18/2006
Status F - Final
Primary References
Document 004010X091A1
Set ID835