The UHIN Electronic Remittance Advice Standard is compatible with all HIPAA requirements.
Purpose: The purpose of this UHIN Standard is to detail the Standard transactions for the transmission of health care remittance advices in the state of Utah.
Applicability: This Standard applies to all electronically exchanged remittance advice transactions for professional, institutional, and dental claims.
Correction: Re-adjudication of a previously finalized claim.
Reversal: Negation of the original adjudication of the claim.
- Standard Remittance Advice Transaction:
The UHIN Standard for electronic remittance advice is the HIPAA 005010x221A1 Technical Report 3 (TR3) and Errata.
See the Washington Publishing Company web site (http://www.wpc-edi.com) to purchase a copy of the TR3.
- Reversals and Corrections:
The reversal and/or correction payment information is sent when a payer has re-adjudicated a claim and must inform the provider of any changes. The reversal claim will mirror the original claim with the exception that dollar amounts are negated. In addition, certain AMT segments may not be sent or may reflect different amounts that were sent in the original remittance advice.
- Overpayment Recovery and use of the Payment Level Balancing (PLB):
Situation I: Reversal and the full recovery occur in the same payment. In this situation the reversal will negate the dollars of the original claim. When the full recovery amount is able to be completed in the same remittance, then the PLB will not be sent.
Situation II: The payer will not be recouping dollars in the remittance. In this situation the payer is providing the reversal and correction information along with a Forward Balance (FB) amount in the PLB. The payer can recoup dollars in a subsequent remittance by using the Forward Balance (FB) qualifier in the PLB.
Situation III: When the payer sends the reversal and correction in a remittance with a Forward Balance owed by the Provider. The provider may send a paper check to resolve the balance forward. In this instance the 835 will be used to acknowledge the receipt of the check by using Authorized Return (72) and Overpayment Recovery (WO) in the PLB Segment to prevent impacting the total payment amount.
In situations II and III it is important that the provider post the reversal and correction to reflect the updated adjudication for the claim, otherwise matching of claim to payment could be invalid.
Situation IV: When the provider sends a manual payment without a request from the payer, then the payer must acknowledge receipt of the payment. The payer will need to use Authorized Return (72) and Overpayment Recovery (WO) in PLB Segments. Send the Patient Control Number (CLM01) from the original claim, or check/ EFT reference number from the refund payment in PLB03-2 of the Authorized Return (72) PLB segment. Send either the Patient Control Number (CLM01) from the original claim or the Payer Claim Control Number (CLP07) in the PLB03-2 of the Overpayment Recovery (WO) PLB segment. This usage is different from the X12 Implementation Guide. The Overpayment Recovery (WO) PLB Segment may also be used to send the providers check/EFT reference number, since recovery does not always relate to a single claim.
- Adjustment Codes:
Payers will use the 835 Group Codes and Claim Adjustment Reason Codes (CARC’s) in their 835 transmissions. The Medicare Remarks Code list will be used by all payers for remittance advice remarks to further explain generic remittance codes. See the national code list for those codes that require remark codes.
The 835 Group and Standard Adjustment Reason codes are revised up to three times per year by the Code Maintenance Committee. The “most recent” versions of these lists are published two months after the most recent Code Maintenance Committee meeting. Currently the Code Maintenance Committee meets the first week in February, June, and October. Hence, the “most recent” version of the Adjustment Reason Code list which will be utilized by UHIN network members are those published in April, August, and December. See the Washington Publishing Company web site (http://www.wpc-edi.com) for details.
The Remittance Advice Remarks Codes (RARC’s) list is published at the same intervals as the Adjustment Reason code lists. The “most recent” version of the Remarks code list will be the one published on the Washington Publishing Company web site (http://www.wpc-edi.com) in April, August, and December.
Recommended usage of Group Codes, Claim Adjustment Reason Codes and Remittance Advice Remarks Codes see appendix A.
Inactive codes: Claim Adjustment Reason Codes change periodically, the following are recommendations:
- Code usage is based upon the adjudication date, not the date of service in the claim.
- When the codes become inactive from the time that the primary payer paid and the time that the secondary claim is created the provider will use the code that was sent originally in the 835.
- If the provider receives an inactive code from a payer, the inactive code should be reported back to the payer and coordination should take place to find an active code to report in the secondary claim. Payers must update to the current code list for future claims. Payers may refer to CAQH CORE rule 360 for requirements on uniform use of codes, and the current version of the CORE code combinations.
- Response Transaction:
Provider translators will utilize the 999 - Functional Acknowledgement transaction, to confirm receipt of the 835 and to report any syntactical or semantic transmission errors. See (999) Implementation Acknowledgement For Health Care Insurance Standard.
- Provider-Assigned Claim Control Number:
Payers must return the value in the 835 CLP01 that was received in the 837 CLM01 for re-association of claim to payment.
In the case where the provider/submitter does not submit a patient control number on either electronic or paper claims, payers will return a “0" in the 835 CLP01 when an 835 is used to return a remittance advice.
- Remits to a Central Office:
In cases where a single amount (check/EFT) is being remitted to a central office, but separate 835's are being sent to individual providers (all of whom report to the central office), the BPR02 (Provider Payment Total) may be less than the total amount sent to the central office. In this case, the BPR02 will be the portion of the total (central office) amount, which would have gone to the provider if they were receiving individual payments rather than the central office receiving a single payment. In this case, the central office would use the check number/EFT number received in TRN02 (1-040) to track all proportional amounts indicated in the 835 received by the individual providers. This way, the BPR02 will balance with the 835.
- No Payment Transactions:
In cases where there is no payment associated with the 835 ST/SE envelope, payers will still transmit a unique financial transaction number in the TRN (TRN02). This financial transaction number must be uniquely tied to the particular 835 ST/SE (i.e., it must be reproducible if it is necessary to retransmit the 835 ST/SE batch), and it cannot be a duplicate of a check or EFT number.
It is not necessary for payers to track a zero-pay financial transaction number inside their adjudication system.
- The 277 Claim Acknowledgment Transaction:
The 835 are used only to report on the final financial statement of claims/encounters, which have been accepted for adjudication. The 277CA transaction cannot be used to report financial information on claims/encounters (see UHIN Claim Acknowledgment Standard for additional information on use of the 277CA).
- Identifying the Plan:
The purpose of this item is to standardize how plan information is identified in the ASC X12 835 transaction. It only applies when a provider is paid at a different rate by different plans under the same payer and the payer combines their plan payments into a single 835. If a payer has multiple plans but payment is paid at the same rate under all the plans, or if the plan issues separate 835s by plan, then this item does not apply. It is used when it is necessary to understand how plan information impacts payment.
To indicate which plan the payment is being made under, use “CE – “Class of Contract” in Loop 2100 REF01 of the 835. REF02 contains the code(s) necessary to convey this information. Payers should develop the identifiers/language necessary to identify to the provider the plan information. The expectation is that, payers will not customize these codes/text strings by provider. Payers should use the same identification for each plan/program/group which impacts payment within their organization.
- Coordination of Benefits Reporting:
Reporting claim adjudication for secondary payer positions requires the appropriate use of Group Codes, Claim Adjustment Reason Codes, and Remittance Advice Remark Codes as described in the TR3 (Implementation Guide). To assist in the consistent and appropriate formulation of the 835, please refer to the Coordination of Benefits Standard.
- Pre-Payment Benefits Reporting:
Advanced Payments and Reconciliation where monies are given in advance and then claims are adjudicated against the funds already paid. When this occurs it is imperative that the remittance advice reflects that the claims are paid, in order for the providers to accurately post to the patients account.
When a claim is adjudicated and reported on the 835, the claim must reflect the payment and any adjustments while the PLB is used to reflect the money from the advanced payment that has been taken in that RA.
The arrangement between the payer and the provider, to do advance payments, should in no way hinder the ability for the provider to post claim details to the patient accounts. The example in the ASC X12 Remittance Advice Implementation Guide section 188.8.131.52 is quite complex. The following is a simple example of the reporting required in the pre-pay benefits situation. All segments are not shown for simplicity and space limitations.
RA1: Providing the advanced payment
RA2: Two claims are adjudicated against the advance payment
- To see use case examples of how secondary commercial payers adjust claims as they are processed, see the Coordination of Benefits Standard.
- Payers will educate providers on the advantages of the automatic posting of electronic remittance advice.
- Payers will adopt the Standard Claim Adjustment Reason Codes and all associated Remittance Advice Remark Codes for the paper/printed Remittance Advice. It is strongly recommended that the Standard Group Codes be sent along with the Reason and Remark Codes on paper.
- The UHIN Standards Committee may function as a discussion forum for requesting Claim Adjustment Reason Codes and Remittance Advice Remark Codes when payers or providers believe there is a need for a new code or modification of an existing code. This is considered best practice but not required.
- While it is not required for the paper remittance advice to be discontinued, once electronic remittance advice is adopted, it is the goal of the payer and provider community to move in that direction.
- It is recommended that testing include a parallel paper and electronic remittance advice for the provider to double check the payment and adjustment reasons.
- Instructions for reporting claims that are denied for requested additional information by the primary payer can be found in the Coordination of Benefits Standard.
- The implementation date for this Standard is January 1, 2012, however payers and providers may voluntarily adopt prior to that date.
- Payers should consider using external tables to house code lists for ease of updates.
- It is recommended that providers understand that the Remittance Advice values in the PLB and adjustments from the CAS segments have an opposite meaning.
- a negative value should be considered a positive number
- a positive value should be considered a negative number
For example, a positive PLB value decreases the payment amount and a negative PLB value increases the payment amount.
Recommended usage of 835
Group, Reason and Remark Codes
GROUP CODE USAGE
Use of the Patient Responsibility (PR) Group Code:
Used commonly with Co-Pay, Deductible, Co-Insurance, Non-Covered
This code identifies to the provider that the amounts identified should be collected from the patient. Payers should not use this code to report outstanding billing issues. Payers should completely resolve all billing issues before sending this code.
Use of the Contractual Obligation (CO) Group Code:
Used when the provider has a contract with the payer or there are regulatory requirements that mandate the provider cannot collect payment from the patient.
This code identifies the discount or adjustment amounts that the provider must apply to the billed amounts. This should not be used by the payer when reporting impact from prior payer payments/adjustments (See instructions for OA)
Use of the Payer Initiated (PI) Group Code:
Used when reporting non-paneled or non-contracted provider adjustments.
This code identifies the discount or adjustment amount that the payer is recommending that the provider apply to the billed amounts. Providers may identify these adjustments as patient responsibility.
Used when secondary payer cannot complete adjudication process because the previous payer has denied the claim for Non-compliance of plan requirements.
The provider should resolve all billing issues before forwarding a secondary claim to subsequent payers. Providers should not consider these adjustments as patient responsibility.
Use of the Other Adjustment (OA) Group Code:
Used for balancing when bundling/unbundling is being reported.
Unbundling would use the OA 94 (Processed in Excess of Charges) with a negative dollar amount.
Bundling would use OA 97 (payment is included in the allowance for the basic service) and an adjustment amount equal to the submitted charge
Used for administrative adjustments
OA is used to identify this as an administrative adjustment relating to other payer paid. Report the "impact" in the appropriate claim or service level CAS segment with reason code 23 (Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.)
OA is used when secondary payer allows more than the submitted amount the claim must still balance This is reported as a CAS segment with a group code OA (Other Adjustments) and a reason code of 94 (Processed in Excess of Charges) with a negative dollar amount.
USAGE OF CLAIM ADJUSTMENT REASON CODES
Claim Adjustment Reason Codes provide the explanation on how the payer paid, denied, or adjusted billed services.
As of this writing the following reason codes require that at least one remark code be sent:
16 Claim/service lacks information which is needed for adjudication.
96 Non-covered charge(s).
129 Prior processing information appears incorrect.
148 Information from another provider was not provided or was insufficient/incomplete
226 Information requested from the Billing/Rendering provider was not provided or was insufficient/incomplete
227 Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete
234 This procedure is not paid separately.
237 Legislated/Regulatory Penalty.
252 An attachment/other documentation is required to adjudicate this claim/service.
A1 Claim/service denied
The reader should refer to the Claim Adjustment Reason Code list posted on www.wpc-edi.com for the most current list of codes and requirements. This list does not preclude remarks codes from being sent with other reason codes. It is recommended that when possible, remark codes should be sent to further explain adjustments or discounts.
USAGE OF REMARKS CODES
Remarks codes provide further detail to the reported adjustment. Providers should ensure that the data is captured and displayed in their practice management systems. See example below;
Payer is reporting a discount. The services billed are more than allowed by the payer’s contract.
CO: Contractual Obligation
222: Exceeds the contracted maximum number of hours/days/units by this provider for this period.
M63: We do not pay for more than one of these on the same day
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