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Back  RFI # 870: Balancing

Formal vs. Informal Help Informal Formal

Submitter

Harvey James

Description

We are finding payers that technically balancing the 835 transaction BUT
they are forcing the claim or transaction to balance using CARC codes that
do not pertain to the patient.

The payers call this force balancing. Is this allowed within the confines
of either 4010 A1 or 5010 implementation guides?

This causes the provider systems great pain and work arounds to not post these CARC adjustment as they are not valid adjustments. This also causes the A/P balance to be incorrect .

Submitter Assigned Keywords

balancing, 835, force balance

Response

This issue is explicitly addressed in both guides. X221 and X091A1 section 1.4 states "The 835 is intended to meet the particular needs of the health care industry for the payment of claims and transfer of remittance information." X221 section 1.10.1.4 and X091A1 section 2.1.4 state "As a remittance advice, the 835 provides detailed payment information relative to the health care claim(s) and, if applicable, describes why the total original charges have not been paid in full."

As such, conveying inaccurate remittance information that doesn't correctly identify why the total original charges have not been paid in full is inconcistent with both guides and is not allowed.
Submission 10/1/2009
Status Date 11/11/2009
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page14
Set ID5010