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Back  RFI # 558: 835 reason code text

Formal vs. Informal Help Informal Formal

Submitter

jj singh

Description

In an 835 - how can a health plan code the exact words of a adjustment reason code on a paper EOB? What specific segments can be used to pass the text of a reason code (could be a paragraph long) at the service level? Thank you.

Submitter Assigned Keywords

835 adjustment reason code text

Response

This issue is explicitly addressed in guide 004010. Section 2.2.4 states "The Claim Adjustment and Service Adjustment Segments provide the
reasons, amounts, and quantities of any adjustments that the payer made either to the original submitted charge or to the units related to the claim or services."
There is no support in the 835 for the proprietary
adjustment reasons used by health plans on their paper remittance advices or for the text of those messages. The standard coding must be used in
the 835. Those messages must be mapped to the Claim Adjustment Reason Codes as well as other locations that combine to convey the entire messge. Some of those other locations are the Remittance Advice Remark codes, Claim Status Code, Class of Contract Code, Corrected Priority Payer Name, and
Crossover Carrier Name.
Submission 5/10/2007
Status Date 8/6/2007
Status F - Final
Primary References
Document 004010X091A1
Section2110
Page148
Set IDcas02