Re: 835 - Medicare Paid in Full

[Jim Whicker]

Bill - One additional comment... I note in your example the expectation to use "PI" as the group code... I'm including, below, a section from the 835 implementation guide regarding usage of the group codes.  In all my years of doing 835's, I haven't seen a 'PI' yet...  99 percent of the CAS's I've seen are covered with PR, CO or CR.  PI and OA are (and should be!) rare.     The Claim Adjustment Group Code, CAS01, categorizes the adjustment reason codes that are ontained in a particular CAS. The Claim Adjustment Group Codes are evaluated according to the following order: 1. Is the amount adjusted in this segment the patient�s responsibility? Use code PR - Patient Responsibility. 2. 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.  An example of a contractual obligation might be a Participating Provider Agreement. 3. In the payer�s opinion, is the amount in this segment not the responsibility of the patient, without a supporting contract between the provider and the payer?  Use code PI - Payer Initiated. 4. Is this claim the reversal of a previously reported claim or claim payment, indicated by Claim Status Code = 22, Reversal of Previous Payment?  Use code CR - Correction and Reversals. 5. If no other category is appropriate, do the following: Use code OA - Other Adjustment. Avoid the Other Adjustment Group Code (OA) for financial adjustments, except when doing predetermination of benefits. >>> Jan Root <[EMAIL PROTECTED]> 05/01/02 11:43AM >>> William Maybe I'm missing something here but anytime the prime pays a service line in full there is nothing more to be done with that line by any subsequent payer, no?  When your company received the claim transaction that service line would look something like this: SV2*REV*HC:proc*100*UN*1~  (the original service line with a charge of $100) SVD*Medicare ID*100*HC:proc*REV*1~ (this shows the service line paid in full by Medicare) there are no CAS segments to this line as it was paid in full. Now, when you send out the 835 transaction you cannot make any further adjustments on this line regardless of your policies because it has already been paid in full.  Therefore, your correct adjustment code on your 835 would be that another payer has paid this amount previously (code 23, commonly used in secondary 835s).  The CAS segment is used to report adjustments to a line/claim, explaining why a claim/line was paid differently than it was billed.  In this case there can be no further adjustments to this line as it has been paid in full. Your 835 would look like: SVC*HC:proc*100*0**0**1~ CAS*OA*23*100~ Hope this helps. Jan Root "Sayman, William" wrote: > We currently receive claims for secondary payment, where Medicare made the > primary payment.  We are trying to determine the appropriate way to create > the 835 CAS segment for the following situation: > > The provider charged $100.00 for the service and Medicare paid that service > in full.  We then receive that claim from the Medicare Intermediary on an > 837COB transaction.  For some reason (timely filing, for example) we do not > even consider paying that service and reject the claim line. > > Would it be more appropriate to create the CAS segment with an adjustment > group code of PI (payer initiated) and an adjustment reason of 23 (paid by > another carrier), or would it be appropriate to create the CAS segment with > an adjustment group code of PI and an adjustment reason of 29 (time limit > for filing has expired). > > Basically, is it more important to a provider to know the payment by the > other insurer (Medicare), or would they want to know the appropriate reject > reason for which we denied the claim.  If anyone has discussed this > situation, or has an opinion on this, please let me know. > > Thanks in advance, > Bill Sayman >