In the CAS X12:Syntax it states
X12 Syntax: 1. L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
while at the element level it states for both the CAS06 and CAS07 SITUATIONAL RULE: Required when CAS05 is present. If not required by
this implementation guide, do not send.
a claim with the following
SVD*74095*132.17*HC:99213**1~
CAS*PR*1*7.83*1*2**1~
because the CAS06 was missing.
Should the claim be rejected when the CAS07 is present and CAS06 is not?
X12 cannot, and will not comment on a receiver’s decision to accept or reject a claim. X12 is limited to interpreting whether or not a usage is consistent with the TR3.
As stated by the CAS06 Situational Rule, the CAS06 must be sent if the CAS05 is present. The presence of the CAS07 does not negate the requirement for a CAS06 as suggested in the example in this request. In business terms, you cannot have an adjustment without having an adjusted amount.
The statement in the request that the CAS07 is required when CAS05 is present is not accurate. The CAS07 is only sent when the CAS05 is present and is a units of service adjustment. The Situational Rule for CAS07 reads "Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send." This units of service restriction applies to all of the Quantity elements in the CAS segment, CAS04, 07, 10, 13, 16 and 19.