Claims with denied status or processed as prim but sent w/CO for invalid name or Expenses incurred prior to coverage. Is CO appropriate. Need examples when CO would be appropriate.
Multiple payers send denied claims with CO cas adj group codes
CLP*09xx00xx26*1*101.0*0**HM*0xxxxE0xxxxA1**1~
NM1*QC*1*TEST*CHRIxxxx****MI*M009xxxx5~
DTM*232*20090729~
DTM*050*20091120~
SVC*HC+87081*101.0*0*0306*0**1.0~
DTM*472*20090729~
CAS*CO*26*101.0~
REF*6R*1~
REF*LU*Y1~
Verify if claim status and cas adj grp code are appropriate
This issue is explicitly addressed in guide 004010X091. Section 2.2.4 states "Is the amount adjusted not the patient’s responsibility under any circumstances due to either a contractual obligation between the provider and the payer or a regulatory requirement?
Use code CO - Contractual Obligation."
CARC code 26 means - Expenses incurred prior to coverage.
This combination of CO and 26 is nonsensical in that it effectively states that there is a contractual requirement prior to the existence of the contract.
Section 2.1.4 states "As a remittance advice, the 835 provides detailed payment information relative to a health care claim(s) and, if applicable, describes why the total original charges have not been paid in full." Providing erroneous information is contradictory to that statement.
Claim Adjustment Group Codes must be applied consistent with the direction in section 2.2.4, or the message in the 835 is erroneous.