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Back  RFI # 689: Claim verses line CAS segments

Formal vs. Informal Help Informal Formal

Submitter

stacey alsdurf

Description

The 835 has a statement in both the 4010A1 guide and the 5010 guide that says "When the Service Payment Information loop is present, adjustments are reported in either the Claim Adjustment or the Service Adjustment Segments but not in both. For example, if a $100 deductible adjustment is taken at the service level, do not repeat that deductible at the claim level. It is preferred that the adjustment be shown at the service level when possible."

The first part of this statement clearly says that CAS segments should be sent at the claim or the line but the second part of the statement uses the SAME adjustment as the example. The 5010 837 guide uses COB examples with CAS segment within the same claim at both the claim and line level but the adjustment codes and amounts are not representing the same adjustments.

Is the intent of both the 837 and 835 guides to allow both claim and line level adjustments within the same claim?

Submitter Assigned Keywords

CAS, COB, adjustments

Response

Yes, if applicable, a claim can have unique adjustments at the claim level and other unique adjustments at the service level. The example accurately reflects our intent in context of balancing. A specific adjustment reported at a service level cannot be repeated at a claim level and visa versa. The intent of the 835 message referenced is to not duplicate the money being adjusted. The claim MUST follow documented balancing procedures.

It is our recommendation to report adjustments only at the service level when reporting service line detail.

Draft 837 Response:
We agree with the 835 workgroup response.
Submission 9/24/2008
Status Date 11/21/2008
Status F - Final
Primary References
Document 004010X091A1
Section2.2.1.2
Page21
Set ID4010A1