I think we may try to go ahead with Mike's or Jan's suggestion of using either the 101 or 110 adjustment reason code initially. I'm concerned that these will result in phone calls instead of conveying what we really want to convey. The 101 suggestion seems to indicate that we expect to pay $0 when we may actually pay something when the claim is filed. But this was also what we came up with. The 110 may make it seem that we thought it was a claim instead of a predetermination, but may actually get the point across to some of the providers.
Therefore we will probably go ahead and request a new code, and when/if it's issued we will simply have to make a quick update to a table on our system. My concern about unsolicited claims status is that from experience there are many providers who never look at it, and again there's the same issue that they won't really be informed that we don't do predeterminations and will call instead. However, it's a good point to consider since our system will create entries on a database so that we can respond to a solicited claims status, and we will need to decide what claims status codes are most appropriate. Thanks for all the suggestions. It was helpful to see that people seemed to go through similar thought processes when looking at this. Jim Griffin Business Systems Analyst CNA -----Original Message----- From: Falbowski, Ellen [mailto:[EMAIL PROTECTED]] Sent: Wednesday, January 16, 2002 11:48 AM To: '[EMAIL PROTECTED]' Subject: RE: Predetermination of Dental Benefits Couldn't this be also handled via the unsolicited 277 claim status? The STC01 could carry E0 (Error in submitted request data) or A3 (Returned as unprocessable) in the Category Code and 187 (Date(s) of service) in the Status Code. -----Original Message----- From: Jan Root [mailto:[EMAIL PROTECTED]] Sent: Wednesday, January 16, 2002 2:17 PM To: [EMAIL PROTECTED] Subject: Re: Predetermination of Dental Benefits Jim You are correct that there is not a good way to do this in the 835. You might try using code '110 - Billing date predates service date' in the claim level CAS but I can see that it would be quite a stretch.... I would suggest that you contact the Codes Maintenance Committee and request a new Adjustment Reason Codes. You might also want to request a new Claim Status Reason Codes if you think you might need this to respond to a claim status inquiry (the same committee handles both code lists). This could be a pre-adjudication rejection. Requests for new codes can be made at http://www.wpc-edi.com/conferences/crc.html. Login and go to the February 2002 Issues and Agenda topic under Issues & Requests (you might have to hit the 'more' button at the bottom of the list). j "J.G." wrote: > Our plan includes both medical as well as limited dental coverage. We do > not do any predetermination of benefits today. If a provider calls in we > tell them we don't predetermine benefits. If they send in a paper form we > respond with a form letter telling them we don't predetermine benefits. If > they ask specific questions on the phone, they may get some additional > information, but nothing that should be close to an actual predetermination. > > The 837 Dental Claim transaction allows for a predetermination request. The > 835 Remittance Advice allows for a response. However, I don't see a way to > indicate that we don't perform predeterminations. Is there a way to do this > in the 835, or is there another way to respond to this? > > Jim Griffin > Business Systems Analyst > CNA > > ********************************************************************** > To be removed from this list, send a message to: [EMAIL PROTECTED] > Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request.
