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Back  RFI # 454: Claim Splitting

Formal vs. Informal Help Informal Formal

Submitter

Ryan Wexler

Description

Is the provider required to report the new representation of the split claims to the secondary in the cob or can the provider continue representing the claim in its combined state?
Can the provider also freely split claims?
If a primary sends a claim level adjustment in the 835 what rules must the secondary payer follow if they split the claim? Can the claim level adjustment be split?
If we have a claim for 200$ consisting of 2 100$ service lines A and B. In the 835, the payer sends claim level adjustments consisting of a 50$ CO45, a 100$ PR1 and 25$ payment for each service. We send this claim to the secondary and they decide to split services A and B into separate claims. What are the rules concerning how those claim level adjustments are shown in the secondary’s 835. Can they split and convert the 50$ CO45 and the 100$ PR to service line level adjustments? If so does that mean that providers can also freely split/convert claim level adjustments and re-represent them as service line level adjustments?

Submitter Assigned Keywords

claim splitting

Response

Please see HIR 455 for further information on how to report primary payments to a secondary payer in the 837.

How the secondary payer handles the claim is dependent upon the the impact of the primary payment/adjustments and subsequently a tertiary payer must account both the primary and secondary payments/adjustments. The preferred method of processing is an allocation of the prior payers' payment/adjustments to submitted charges of the higher allowed charges. This results in an adjustment using Group Code OA with CARC 23 at either the claim or service level, as appropriate.

Recommendation

The workgroup recommends that splitting of claims only occur for valid business reasons and not due to technical limitations. Valid reasons include BUT ARE NOT LIMITED TO; part of the claim is pended; or if some of he service lines cross a benefit year; or some have to be paid via one plan and the others a different one, etc. Invalid reason include; inability to handle XX number of services lines, screen limits, etc.
Submission 9/20/2006
Status Date 3/30/2007
Status F - Final
Primary References
Document 004010X091
Section2.2.11
Page33
Set ID835