Section title: Requests for Interpretation
RFI #
2353
Can CAS03 be zero?
Description

Can the value of CAS03 in the 2100 be equal to 0, to facilitate reporting claim level issues when the adjustments are taken at the line level? A payer is sending us a generic code A1 to report a claim header level message when the claim members id was not found, valid or on file. We can't post the 835 without the additional information. Header level claim adjustment reason codes are not being reported in their 835 because the adjustments are taken at the line level. The line level adjustment codes do not reflect the header level reason (which is reported on the paper EOB). Having the header level adjustment reason code, in the 835 transaction, is critical to correct automated processing of the payment file.

Response

Although created for 4010, RFIs 344 and 499 provide a response that clearly indicates CAS03 cannot be zero, and still apply to 5010. The 2100 Loop CAS Claim Adjustment Segment situational rule reads “Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send.”, and the 2100 Loop CAS Claim Adjustment Segment TR3 Note 1 reads “Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.” The 2110 Loop CAS Service Adjustment Segment situational rule reads “Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send.”

The 2100 and 2110 Loop CAS Segment TR3 Note 3 states “…the first adjustment must be the first non-zero adjustment…”

All of this information together clearly indicates that the adjustment amount reported in CAS03 is adjusting the payment amount, and cannot be zero.

RFI Recommendation

Remittance Advice Remark Codes (RARCs) can be used to convey information related to the claim that is not associated to a specific amount. RARCs can be reported at either the 2100 (claim) or 2110 (service) level. In addition, Claim Status Code (CLP02) = 4 should be used when the Patient / Subscriber is not recognized, and the claim was not forwarded to another payer.

DOCUMENT ID
005010X221