1. What is the 835, really? How can we get it to work?

2. Intent of the 835 Manages the claim payment and remittance advice information One of many communication devices between payer and provider

3. Other Electronic Devices HIPAA Mandated: The health care claim status request and response (276/277) Not HIPAA Mandated: The health care claim acknowledgment (277) The health care claim request for additional information and response (277/275) The unsolicited claim status (277)

4. The 835 Pay-off Allows for auto-posting of claim payment information Facilitates cash-flow Significantly decreases expenses associated with paper

5. Key Components of the 835 Relationship between Claim Adjustment Group Codes Claim Adjustment Reason Codes Remittance Advice Remark Codes

6. Claim Adjustment Group Codes Provide the general reason for a claim being adjusted – Contractual Obligation (CO) – Correction and Reversal (CR) – Other Adjustments (OA) – Payor Initiated Reductions (PI) – Patient Responsibility (PR) Critical to auto-posting

7. Claim Adjustment Reason Codes Provide the reasons for the financial adjustment to the service and/or claim Relate to the Group Code May have up to 6 Adjustment Reason Codes per segment Critical to a provider understanding why an adjustment occurred

8. Remittance Advice Remark Codes Provide non-financial information related to the payment and/or adjustment of a given service. These are informational remarks only and do not impact the payment Note: While this is not a required element in the 4010A1, there are Claim Adjustment Reason Codes that require use of this segment

9. Providing the Total Picture For any claim or service line adjustment there must be a Group Code and an Adjustment Reason Code. Further detail for a service can be provided by the Remittance Advice Remark Codes

10. Other Informational Data Elements

11. AMT Segment Used to convey information only and does not impact the payment May tie a PLB adjustment back to a specific claim or service, when applicable. – Not all PLB adjustments can be associated with a claim or service.

12. Claim Level AMT Segment Related to PLB Segment – Prompt Pay Discounts PLB Qualifier: 90 – Interest PLB Qualifiers: 51, L6 Not Related to PLB Segment – Per Day Limit – Patient Paid Amount – Tax – CMS Category 1 – 5 Reporting

13. Service Level AMT Segment Related to PLB Segment – Late Filing Reduction/Penalty PLB Qualifier: 50 Not Related to PLB Segment – Actual Allowed Amount for the Service – Net Billed – Tax – Claim before Taxes – CMS Category 1 – 5 Reporting

14. Claim Status Code Communicates – If claim was processed as primary, secondary, or tertiary (COB) and/or if it was forwarded to another payer. – If claim was denied and another code does not apply, e.g., a patient can not be identified as the payers insured and it was not forwarded to another carrier. – Reversals – Predetermination pricing, no payment

15. DRG Code and Weight Specific to Institutional Claims Required when the claim was adjudicated using a DRG – CLP11 reports the DRG Code – CLP12 reports the DRG Weight

16. Adjudicated verses Submitted Procedure Code If the adjudicated procedure is DIFFERENT than the code that was submitted, SVC06 must be used. – SVC01 is used to reported the ADJUDICATED code – SVC06 is used to report the ORIGINAL code that was submitted on the claim

17. MIA Segment: Inpatient Information Not just limited to Medicare Used to convey inpatient benefit information – Outlier Quantity – Cost Report Day Amount – Non-payable Professional Component Amount

18. MOA Segment: Outpatient Information Not just limited to Medicare Used to convey outpatient benefit information: – Reimbursement Rate – Payable Amount – Non-payable Professional Component Amount

19. QTY Segment: Claim Supplemental Information Use to convey quantity information: – Actual Covered Amt./Co-insured – Actual/Estimated Life-time Reserve – Number Non-Covered Days/Blood Units – Outlier Days – Prescription – Visits – CMS Category 1 - 5 Reporting

20. Benefits of Informational Sections 1. Gives complete information to the provider regarding the handling of their claim 2. Minimizes the need for a provider to call the payer, which reduces expenses

21. Questions?