Change Request Detail
No.
1039
Date
2/27/2006
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
Request pertains to the 837 and 835 Transactions.  Per HIRs 277 and 344, the 835 transaction does not allow a zero dollar amount in the CAS segment however there is no such rule/interpretation of the same requirement in the 837 transaction.  Currently, when a provider bills Medicare and the claim is crossed over to Medicaid at the beginning of a new year, the client needs to meet their Medicare deductible which is resulting in the Medicaid receiving a CAS segment with a zero dollar amount in the 837 transaction.  In order to report this amount in the corresponding 835 transaction, a CAS segment with a zero dollar amount is required.

In addition, to report multiple denial reasons for a claim, zero dollar amounts need to be reported in the CAS segment.  For example, when a claim or claim detail denies for multiple reason, each claim adjustment reason code needs to be reported to the provider to allow for the correction of all denial reasons before resubmitting the claim.  An example of this occurrence is as follows: CAS*OA*A1*3450**17*0**15*0
Suggestion
On behalf of Medicaid and commercial payers, zero dollar amounts need to be allowed in the CAS segment in the 835 transaction.
DSMO Category
D
Recommendation
Disapprove. A Data Maintenance request was approved for the standard version 005030 that will allow the CAS segment to have a repeating element. This will allow for multiple reason codes to be assigned to a dollar amount and eliminate the need to report adjustment reason codes with zero dollar amount. This will be incorporated into the next version of the HIPAA implementation guide.
Appeal Recommendation