When a payer reimburses the member/patient/subscriber - The assumption is the money that was paid to the sub would be reported as a CAS with CARC 100 so the claim or line would balance as nothing would be shown in reimbursement SVC03. The question is what group code should be reported. The tr3 does not advise. In some instances it may be known if the provider collected the money from the patient up front and in other cases it may not be known - Please advise what the group code would be OA or PR?
Example Charge is 100, allowance is 75. Provider is not participating The 835 would report PR 45 for $25 and a ?? 100 for $75. what is the group code that would be recommended?
The ASC X12 “Health Care Claim Payment/Advice” Technical Report Type 3 005010X221A does not explicitly address which Claim Adjustment Group Code (CAGC) is to be used with Claim Adjustment Reason Code (CARC) 100.
The ASC X12 “Code Value Usage in Health Care Claim Payments and Subsequent Claims” Technical Report Type 2 does provide X12’s opinion of which CAGC(s) are appropriate with each CARC. In the case of CARC 100, the only appropriate CAGC is PR – Patient Responsibility.