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Back  RFI # 499: 835 CAS03

Formal vs. Informal Help Informal Formal

Submitter

Tim Boyd

Description

Can the value of CAS03 in the 2100 be equal to 0, to facilitate reporting claim level issues when the
adjustments are taken at the line level? A payer is sending us a CAS*CO*42 at the line. Their paper EOB
reports a claim level message that there is a patient name/ID mismatch. We can't post the 835 without the additional information. Header level claim adjustment reason codes are not being reported in the their 835 because the adjustments are taken at the line level. The line level adjustment codes do not reflect the header level reason (which is reported on the paper EOB). Having the header level adjustment reason code, in the 835 transaction, is critical to correct automated processing of the payment file.

Response

This issue is explicitly addressed in guide 004010X091. Usage of a zero in CAS03 is prohibited.

Recommendation

The 2100 CAS note states "...report claim level adjustments that cause the amount paid to differ from the amount originally charged." $0 is not consistent with that requirement. As stated in the question, the payer is not coding the 835 correctly. This message can be reported at either the claim level or the line level. Either way, "CAS*CO*42" does not represent the business message. The payer should have been using claim adjustment reason code 140 in CAS03. That code means "Patient/Insured health identification number and name do not match." Payers must accurately report the same message in the 835 coding as is printed on their paper remittance advice to the provider.
Submission 12/5/2006
Status Date 1/26/2007
Status F - Final
Primary References
Document 004010X091A1
Section3.1
Page95
Set ID835