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Back  RFI # 976: Verify use of CO clm nc denied

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

Claims with denied status or processed as prim but sent w/CO for invalid name or Expenses incurred prior to coverage. Is CO appropriate. Need examples when CO would be appropriate.

Multiple payers send denied claims with CO cas adj group codes

CLP*09xx00xx26*1*101.0*0**HM*0xxxxE0xxxxA1**1~
NM1*QC*1*TEST*CHRIxxxx****MI*M009xxxx5~
DTM*232*20090729~
DTM*050*20091120~
SVC*HC+87081*101.0*0*0306*0**1.0~
DTM*472*20090729~
CAS*CO*26*101.0~
REF*6R*1~
REF*LU*Y1~

Verify if claim status and cas adj grp code are appropriate

Submitter Assigned Keywords

Using CO rather than PR

Response

This issue is explicitly addressed in guide 004010X091. 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 26 means - Expenses incurred prior to coverage.

This combination of CO and 26 is nonsensical in that it effectively states that there is a contractual requirement prior to the existence of the contract.

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." Providing erroneous information is contradictory to that statement.

Claim Adjustment Group Codes must be applied consistent with the direction in section 2.2.4, or the message in the 835 is erroneous.
Submission 3/1/2010
Status Date 5/21/2010
Status F - Final
Primary References
Document 4010 Combine
SectionDetail
Page149
Set IDcas01
Loop2110
Segment Position01