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Back  RFI # 445: Split Claims with DRGs

Formal vs. Informal Help Informal Formal

Submitter

Bob Resh

Description

In a case where an inpatient claim has a part that is paid by DRG and a part that is fee for service, is it consistant with the guide to split that claim so that 1 claim has all of the DRG parts, and pays at the claim level without service detail, and a second claim contains the fee for service parts and reports back the service detail?

Submitter Assigned Keywords

DRG Split Claim

Response

This situation is one for which splitting a claim is valid and appropriate.

Recommendation

To assist the provider in reconciling their patient accounts, the payer must retain
and return basic original claim information in each of the adjudicated claims. The
original Claim Submitter’s Identifier (CLM01) must be returned on all split claims
in CLP01. The provider’s original submitted line item control number from the
claim must be returned in the REF segment, loop 2110. If the original claim did
not contain a specific line item control number for the service lines, the line item
sequence number (LX01) from the original claim must be used in the 835 REF
segment instead.
Submission 9/5/2006
Status Date 10/20/2006
Status F - Final
Primary References
Document 004010X091
Section2.2.11
Page33
Set ID835
Secondary References
RFI ID 401
Document 004010x091
Section2.2.4.1
Page25
Set ID835