Section title: Requests for Interpretation
RFI #
2570
OA-23 adjustments at claim and charge level (835) suggested updates
Description

Recently, a few payers have started sending secondary payments with OA-23 adjustments at both the charge and line-item level to indicate the impact of the prior payer.  This has caused numerous issues when attempting to import the 835 into the billing software as the vendor is unable to determine the payment amount of the primary payor properly.  This causes the remittance to have to be manually posted due to the need for a manual calculation.

My question is, is it against the guide or best practice to use OA-23 at both the claim and line-item level?  See the example below.  It was my understanding that if service line information is returned it should be consistent.

Scenario

In the example below, the payer sent OA*23 at the claim level that the paid amounts indicated in the SVC line items are not the actual paid amount.  You have to add up the two SVC payment amounts, then reduce the payment by the claim level OA23.

The payer is returning the prior payers CO-45 at the SVC level, and the prior payers paid amounts at the claim level CAS segment.

SVC Paid = 460.92 (Charge line 1 paid) + 33.68 (Charge line 2 paid) = 494.60 - 395.68 (Claim level OA23 adjustment) = 98.92 (paid amount)

CLP|CLAIM #|2|1863|98.92||12|XXXXXXX|41|1~

CAS|OA|23|395.68~

NM1|QC|1|FIRST NAME|LAST NAME||||MI|XXXXXXXX~

NM1|82|2|AGENCY NAME|||||XX|############~

REF|1L|XXXXX~

SVC|HC^A0429^PH|1800|460.92||1~

DTM|472|20220110~

CAS|OA|23|1339.08~

AMT|B6|460.92~

SVC|HC^A0425^PH|63|33.68||4||0~

DTM|472|20220110~

CAS|OA|23|29.32~

AMT|B6|33.68~

RFI Response

Please refer to 1.10.2.4 Claim Adjustment and Service Adjustment Segment Theory.  “The summation of the adjustments at the claim and service levels is the total adjustment for the entire claim.  Service level adjustments are not repeated at the claim level.”  

 

“Repeated”  in 1.10.2.4 does not mean you cannot use the same adjustment CARC code on both the service and claim levels.  It means you cannot adjust the same dollars twice.
 

In this situation the COB impact is one adjustment and be reported at the  line OR claim level.  

CARC 23, per the description and intention, must include the sum of both the prior payment(s) and adjustment(s).  The prior paid amount(s) and adjustment(s) cannot be reported separately in the 835.

 

Refer to section 1.10.2.13 of the 835 TR3 and RFI 2143 for instruction on how to calculate the payments and contractual reductions that have already been posted by the provider and report those amounts associated to CARC code 23.

Related RFIs 1294, 1535, 2143

DOCUMENT ID
005010X221