What is the 835, really? How can we get it to work?

What is the 835, really?

How can we get it to work?

Intent of the 835

Manages the claim payment and remittance advice information

One of many communication devices between payer and provider

Other Electronic Devices

HIPAA Mandated: The health care claim status request and response

(276/277)

Not HIPAA Mandated: The health care claim acknowledgment (277) The health care claim request for additional

information and response (277/275) The unsolicited claim status (277)

The 835 Pay-off

Allows for auto-posting of claim payment information

Facilitates cash-flowSignificantly decreases expenses

associated with paper

Key Components of the 835

Relationship between Claim Adjustment Group Codes Claim Adjustment Reason Codes Remittance Advice Remark Codes

Claim Adjustment Group Codes

Provide the general reason for a claim being adjusted– Contractual Obligation (CO)– Correction and Reversal (CR)– Other Adjustments (OA)– Payor Initiated Reductions (PI) – Patient Responsibility (PR)

Critical to auto-posting

Claim Adjustment Reason Codes

Provide the reasons for the financial adjustment to the service and/or claim

Relate to the Group Code May have up to 6 Adjustment Reason Codes per

segment Critical to a provider understanding why an adjustment

occurred

Remittance Advice Remark Codes

Provide non-financial information related to the payment and/or adjustment of a given service.

These are informational remarks only and do not impact the payment

Note: While this is not a required element in the 4010A1, there are Claim Adjustment Reason Codes that require use of this segment

Providing the Total Picture

For any claim or service line adjustment there must be a Group Code and an Adjustment Reason Code.

Further detail for a service can be provided by the Remittance Advice Remark Codes

Other Informational Data Elements

AMT Segment

Used to convey information only and does not impact the payment

May tie a PLB adjustment back to a specific claim or service, when applicable.– Not all PLB adjustments can be associated with a

claim or service.

Claim Level AMT Segment

Related to PLB Segment– Prompt Pay Discounts

PLB Qualifier: 90

– Interest PLB Qualifiers: 51, L6

Not Related to PLB Segment– Per Day Limit– Patient Paid Amount– Tax– CMS Category 1 – 5 Reporting

Service Level AMT Segment

Related to PLB Segment– Late Filing Reduction/Penalty

PLB Qualifier: 50

Not Related to PLB Segment– Actual Allowed Amount for the Service– Net Billed– Tax– Claim before Taxes– CMS Category 1 – 5 Reporting

Claim Status Code

Communicates – If claim was processed as primary, secondary, or

tertiary (COB) and/or if it was forwarded to another payer.

– If claim was denied and another code does not apply, e.g., a patient can not be identified as the payers insured and it was not forwarded to another carrier.

– Reversals– Predetermination pricing, no payment

DRG Code and Weight

Specific to Institutional Claims Required when the claim was adjudicated

using a DRG– CLP11 reports the DRG Code– CLP12 reports the DRG Weight

Adjudicated verses Submitted Procedure Code

If the adjudicated procedure is DIFFERENT than the code that was submitted, SVC06 must be used.– SVC01 is used to reported the ADJUDICATED code– SVC06 is used to report the ORIGINAL code that

was submitted on the claim

MIA Segment: Inpatient Information

Not just limited to Medicare Used to convey inpatient benefit information

– Outlier Quantity– Cost Report Day Amount– Non-payable Professional Component Amount

MOA Segment: Outpatient Information

Not just limited to Medicare Used to convey outpatient benefit information:

– Reimbursement Rate– Payable Amount– Non-payable Professional Component Amount

QTY Segment: Claim Supplemental Information

Use to convey quantity information:– Actual Covered Amt./Co-insured– Actual/Estimated Life-time Reserve– Number Non-Covered Days/Blood Units– Outlier Days– Prescription– Visits– CMS Category 1 - 5 Reporting

Benefits of Informational Sections

1. Gives complete information to the provider regarding the handling of their claim

2. Minimizes the need for a provider to call the payer, which reduces expenses

Questions?