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Back  RFI # 954: Denied clm on 835 w/CO45

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

Need verification if payor file is compliant when sending a denied status and using CO45 as cas reason code.

Exa Status code 4 and only cas grp code and reason code is CO*45
CLP*xxxxxx7100*4*10418.54*0**12*2009xxAQxxxx*13*1***0~
NM1*QC*1*test*denied*R***MI* xxxxxxxx0~
NM1*IL*1*test*spouse*M***MI* xxxxxxxx0~
REF*1W*xxxxxxxx0~
DTM*050*20091102~
SVC*NU>0240*10418.54*0**1**0~
DTM*472*20091026~
CAS*CO*45*10418.54~

The CO45 contractual obligation is auto writing off in our base system. Payor insists the use of CO45 is appropriate since the IG is so vague for that code.

Submitter Assigned Keywords

CO45 w/status cd 4 denied

Response

This issue is explicitly addressed in guide 004010X091A1. Section 2.1.4 states "As a remittance advice, the 835 provides detailed payment information relative to a health care claim(s) and, if applicable, describes why the total original charges have not been paid in full." Section 2.2. states "The 835 is used to transmit payment and data needed for the posting by a provider subsequent to the adjudication of a claim." Therefore, the 835 must describe why the original charges are not being paid in full. That message must be accurate.

Section 2.2.4 states "Is the amount adjusted not the patient’s responsibility under any circumstances due to either a contractual obligation between the provider and the payer or a regulatory requirement? Use code CO - Contractual Obligation." CARC Code 45 means "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability)." CLP02 code 4 means "Denied".
(continued in the Recommendation)

Recommendation

(conitnued from the Response)
These codes create a message that reads like "this claim is denied, the fee schedule amount is $0.00, and this amount must be accepted as payment in full." That message is non-sensical from a busines perspective. If the claim is truly denied, then the actual reason for the denial must be reported in the CAS segment.

In addition, the reported SVC segment is stating in SVC05 that 1 unit of service is being paid, and SVC07 states that zero units were submitted. Unless zero units were submitted on the service line, that statement is also non-sensical, inconsistent with the rest of the message, and inaccurate.
Submission 2/3/2010
Status Date 2/24/2010
Status F - Final
Primary References
Document 004010X091A1
Section2110.cas
Page150
Set ID835
Table2
Loop2110
Segment PositionCAS02