Can someone verify that the following assumptions are valid? I can't find any
specific documentation in the 837 IG's, the FAQ's, the Sequencing White Paper
, or the Federal register for Transactions and Code Sets.
I'd appreciate comments, especially if you can point me to supporting
documentation.
Thanks, Dennis
1) The 837 "adjustment" process is only to be used if the original method of
claim entry was an 837 (see page 159 of Institutional IG, pages 173/174 of
Professional IG) .
2) We can advise providers/clearinghouses (e.g., Trading Partner Agreement
and/or Companion Guide) that we will only accept 837 "adjustment" transactions
if the original input was 837. (They would follow current state practices if
the claim was not originally submitted via 837).
3) We can advise the providers/clearinghouses what 837 fields are the minimum
required for us to accept an 837 "adjustment" transaction. We are subject to
generic 837 rules about requesting info from providers.
Examples: a) The minimum requirement for an 837 "adjustment" could
be all required 837 fields, plus any situational fields that are in our Trading
Partner Agreement/Companion Guide as being necessary to process an 837
"adjustment".
b) If we requested attachment data to
process the original claim, we cannot request the same data again. If the
provider indicates (for example in an NTE segment) that there is updated
material, we can request that it be sent before we complete our business
analysis of the "adjustment" request.
c) If a field is totally situational it does
not need to be entered on the 837 "adjustment " request.
However, if that data was made available to us on the original claim submission,
and there's no indication that updated material is available, we cannot ask for
it again.
4) When the original claim was submitted via 837, and no action results from a
provider/clearinghouse 837 "adjustment" request, we are not obligated to produce
an 835. An example is where our business evaluation shows us that additional
allowance and/or payment should not be extended. We can use existing forms of
notification to advise the provider that no claims system action is being taken.
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