Section title: Requests for Interpretation
Processing Reversals and Corrections

When creating an 835 and notifying a provider of a reprocessed claim, payors supposed to follow the guidelines laid out in for reversals and corrections. This question pertains to the reversal segment of these guidelines.

1) Does this interpret that the payor is to use the same ANSI Group, Reason, and Remark codes as the originally processing with status code 22 and negative amounts for the reversal?  

2) And should the reversal process in the 835 before the corrected processed transaction?


For question #1:
Payor originally sent 835 claim for payment ($50)  with ANSI codes CO45 ($75) and PR1 ($25)

If payor reprocesses to change any of the amounts in the originally processing, would the reversal part of the reprocessing look like:

1) Reversal: payment ($<50>) with ANSI codes CO45 ($<75>) and PR1 ($<25>)

or can the payor use any ANSI code combination to explain why they are reversing the original transaction:

2) Reversal: payment ($<50>) with ANSI codes CO216 ($<75>) and PRA0 ($<25>)

ANSI codes are not necessarily accurate but wanted to show the 2 different types of reversals as scenarios.

For question #2:
As for when in the 835 the transactions should be seen, would the 835 show the reprocessed transaction before the reversal or the reversal before the reprocessed transaction:

Scenario: Which way is appropriate?
Transaction with status 22 (reversal)
Transaction with status 1 (reprocessed claim, not original processing)

Transaction with status 1 (reprocessed claim, not original processing)
Transaction with status 22 (reversal)

RFI Response

Section describes the reporting for reversal claims that address the questions. 

As it relates to what is required to report in the Reversal: “Reversing the original claim payment is accomplished with code 22, reversal of previous payment, Send original Claim Adjustment group codes in CAS01; and appropriate adjustments. All original charge, payment, and adjustment amounts are negated.” 

The reversal claim must report all of the original Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) when required by the CARC, and Claim Adjustment Group Codes that were previously sent in the prior 835 ERA. This supports the provider backing out of their systems, the prior remittance information and then when they receive the correction, that 835 ERA can be posted accordingly. 

As it relates to the order of the reversal and correction this section also states:    
“Reverse the original payment, restoring the patient accounting system to the pre-posting balance for this patient. Then, the payer sends the corrected claim payment to the provider for posting to the account.” 

The payer would report the 835 with the order of the reversal for the first claim and then the adjusted claim. 
This was addressed in RFI 1944.