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Back  RFI # 645: CAS*CO*45 v. CAS*OA*94

Formal vs. Informal Help Informal Formal

Submitter

Peter Anderson

Description

When a health plan pays above the submitted charge, what is the appropriate CAS to use?

Is CAS*CO*45 with a negative amount ever appropriate?
Is CAS*OA*94 preferred (note that the 5010 IG limits OA to bundling, predetermination, and COB, although an example uses CAS*OA*94 to pay above the submitted charge)?
Or, is CAS*CO*94 the preferred choice?

Submitter Assigned Keywords

835 CAS CO*45 OA*94

Response

This issue is not explicitly addressed in guide 004010X091A1. See the recommendation below.

Recommendation

For the situation described, a CAS*CO*94 adjustment with a negative dollar amount is the best representation of the actual business situation. Since code 45 reads "Charge exceeds fee schedule", usage of 45 with a negative dollar amount is only appropriate with a reversal of a previous payment.
Submission 4/21/2008
Status Date 6/17/2008
Status F - Final
Primary References
Document 005010X221
Section3.3.3.1
Page236
Set ID835
Table2
Loop2110
Segment Position0900
Segment IDCAS
Element Position01
Industry NameClaim Adjustment Group Code
Code ValueOA
Secondary References
RFI ID 581
Document 005010X221
Section1.10.2.4
Page22
Set ID835