Section title: Requests for Interpretation
RFI #
1573
5010 835 CARC 27 on Reversal
Description

A claim is originally denied with CARC 27 and a Coverage Expiration Date is returned in the 835.

Later, membership is updated and the claim is adjusted to pay.

The reversal record returned the original CARC 27, but we no longer have a coverage termination date to return since membership records are updated.

Does this follow the rules of the TR3?

RFI Response

This is explicitly addressed in guide 005010X221. Section 1.10.28 (Reversals and Corrections) doesn't include any requirement related to the Coverage Exiration Date DTM segment in the 2100 loop. The situational rule on the Coverage Expiration Date DTM segment states "Required when payment is denied because of expiration of coverage. If not required by this implementation guide, do not send." Since the reversal of a previous adjudication (2100 Loop CLP02 value 22) that used Claim Adjustment Reason Code 27 (Expenses incurred after coverage terminated) is not itself denying payment due to expiration of coverage, the situation in the rule is not met and the 2100 loop Coverage Expiration Date DTM segment must not be sent.

Therefore, not sending the Coverage Expiration Date DTM segment in this scenario does follow the rules of the TR3.

DOCUMENT ID
005010X221