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Back  RFI # 732: 5010 835 Healthcare Policy ID

Formal vs. Informal Help Informal Formal


Pamela Maklari


In the TR3 for the 835, version 5010, a Healthcare Policy ID (REF) segment is situationally required. This segment is in the 2110 loop. Can you provide clarification on usage in the event that a CARC is designated as requiring a Healthcare Policy ID (assuming all other conditions in the situational rule are met) and the CARC is used in the claim level CAS segment?

Submitter Assigned Keywords

5010 Healthcare Policy ID


CARCs used at the claim level that suggest a Medical policy may be needed impose no obligation (or possibility) of including a Medical Policy identification.

This REF only exists at the service level. Therefore if no service lines are sent, then this REF segment cannot be used. As noted, several requirements must come into play in order for this segment to be required:

1. A codified policy list must exist, e.g., Medicare policies
2. The codified list is accessible to any entity receiving the 835, not just contracted providers
3. PER references location of codified list
4. A service level adjustment is based on a codified policy


The workgroup will evaluate business need for claim level Medical Policy REF for future versions.
Submission 2/16/2009
Status Date 4/20/2009
Status F - Final
Primary References
Document 005010X221
Set ID835
Segment Position1000
Segment IDREF
Industry NameHealthcare Policy Identification