A health plan (HP) has implemented a policy where a pre-payment audit is conducted when an 837I TOB 11X claim charge reaches a threshold. The HP requires the provider to send a separate itemized list of charges that includes the underlying proc codes for aggregated rev codes from the 837I (proc codes not situationally required for this scenario).
The audit process, which is conducted by a 3rd party, determines which proc codes from the itemized list are allowable vs non-allowable. The HP sends an 835 that includes the SVC with the rev code, billed amount, units paid, and corresponding CAS segments. The provider is unable to determine from the 835 which proc codes were allowed vs non-allowed as a result of the audit. The 3rd party then mails a paper report to the provider with the non-allowable line-item proc codes.
Is the HP required to split the submitted service claim line and report the individual proc codes in the 835 as outlined in 184.108.40.206.1 Service Line Splitting for the above scenario?
The 835 is required to send back the original submitted revenue codes and procedures if used in adjudication that were submitted on the 837. AS the itemized bill is not considered part of the ‘original submitted 837 claim’ the information contained in the itemized bill is not required to be sent back on the 835. The payer would be required to send back the revenue codes and the specific dollars being denied in the 2110 CAS and LQ segment with the appropriate group code, CARC code and RARC as applicable.
Splitting as defined in section 220.127.116.11.1 would not be applicable as the original 837 submitted only contained Revenue codes not procedure codes. The adjudication of the given line can be handled within that line and 2110 CAS and LQ segment.
The submitter should submit a maintenance request at www.x12.org to request the ability to report the data to meet the exact need for this business scenario.