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Formal vs. Informal Help Informal Formal


Jan Wheeler


I would like to verify if an insurance company is utilizing the 835 correctly.
The following is a sample of the transactions we are receiving.
Our issue above is the insurance is reporting a Patient Responsible (PR) amount of $899.98 and $10.00. The insurance states the $899.98 is balanced out by Other Adjustment (OA) code 94 and the only amount the patient is responsible for is $10.00.
Is it compliant to utilize the PR and then the OA to off set an amount reported as PR?

Submitter Assigned Keywords

CAS PR 835


The OA group code cannot be used to offset a PR group code adjustment.
Based upon the information provided the Workgroup cannot see any business reason for the offsetting 899.98 dollar amounts. The Patient responsibility amount in the CLP05 must be accurately reflect the NET amount the patient owes the provider.
Submission 12/21/2006
Status Date 3/30/2007
Status F - Final
Primary References
Document 004010x091
Set IDcas01
Segment Position020