Section title: Requests for Interpretation
RFI #
2536
Rejecting Valid CPT HCPCS Codes
Description

Can a payer reject any CPT or HCPCS that is effective and valid for the dates of service, on the basis that the patient's plan does not cover it?

The payer cites the 277CA TR3 1.4 – Business Usage section as being silent on the issue.

We interpret 005010X222 TR3, Section 1.12.2, to indicate a Payor cannot construe situational rules to reject a claim for information they may not use. This section goes on to say the purpose is to enable proper adjudication for any potential downstream payers as well as allow affected providers to collect and report information consistently for all trading partners when desired. As a result, the submitter is not restricted from sending the information to other payers in addition to the specific payer that has a known adjudication impact.

Our issue is that if a primary payor is allowed to reject a claim on the basis they do not cover the service, that the claim cannot ever be forwarded to the patient's secondary insurance coverage for adjudication.

We feel as long as the HCPCs if valid for the dates of service and type of bill, it should be accepted and denied on an 835 to allow for it to be forwarded to the next payer to adjudicate.

Can we have a clear decision that whether a payor can or cannot reject a valid HCPCs solely on the basis that service is not eligible under the patient's contract?

RFI Response

It is outside the purview of X12 to comment on payer policy.  In the 277CA section 1.4 it states that pre-adjudication validation does vary from system to system.  The standards are silent on the business validity of the submitted claim data content.

RFI Recommendation

The AMT- Coordination of Benefits (COB) Non-covered Amount segment can be used to directly convey to the downstream payer the charges that have not been adjudicated by the primary payer.  It is suggested that the billing entity collaborate with the downstream payer to use this segment.

DOCUMENT ID
005010X222