RFI Browser

Back  RFI # 455: Claim Level Adjustments

Formal vs. Informal Help Informal Formal


Ryan Wexler


My accounting system is service line level based. When we receive claim level adjustments like a deductible or even a CO45 can we convert them into service line level adjustments? So for instance, lets say I received a 100$ deductible adjustment at the claim level and this claim consisted of 4 50$ service lines that were each paid 25$ each. Could I instead represent this claim level adjustment as 4 25$ deductible service line level adjustments? Would this be an acceptable representation when passing this on to the secondary in the 837 COB?

Submitter Assigned Keywords

Claim Level Adjustments


For COB claims, the 4010A1 837 claim implementation guides specify that adjustments be reported at the same level, claim or line, as they were determined by the prior payer. In the CAS Claim Level Adjustment segment in loop ID-2320, note 1 explains that this segment (claim level) is used to report prior payers' claim level adjustments. Note 4 states that this segment is required if the claim has .... claim level adjustment information.

It would be difficult or impossible for the COB payer to determine its liability if the provider arbitrarily split claim level Contractual Obligation amounts to the lines. The COB payer would not have an accurate listing of the provider's obligations with the prior payer. As a result, the COB payer could underpay or overpay the claim.
Submission 9/20/2006
Status Date 11/22/2006
Status F - Final
Primary References
Document 004010X098A1
Set ID837