Is it appropriate to send CAS*OA in situations outside of Sections 1.10.2.6, 1.10.2.7, or 1.10.2.13 (as described in the ANSI spec), particularly in place of CAS*CO when the provider is noncontracted?
We were looking to charge the claim adjustment group code (CAS01) to OA for noncontracted providers. If the claim is for a contracted provider, we would keep using CO as our claim adjustment group code.
Would this be considered noncompliant?
Formal Interpretation
Please see the description of group code OA, which states to avoid using except for the business situations described in Sections 1.10.2.2, 1.10.2.7, and 1.10.2.13. While the guide is not explicit to say do not use other than those conditions, the best practice would be to only use in those situations. The intention of group code OA is to direct the receiver to look at other adjustments reported in the claim or in the case of secondary reporting, prior payer adjustments for posting the claim adjudication and payment information. Group code OA does not support clear direction on liability of the adjustment. Additionally, please refer to the specific CARC’s that have the description notes “use only with group code OA” and “use with group code CO or OA.”
If the intent of liability for noncontracted provider is to relay patient is responsible, then group code PR would be used.
If in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer, then group code PI would be appropriate.
If there is a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment, then group code CO would be used.
Use CAGC PI “when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer.”