Change Request Detail
No.
1080
Date
6/3/2009
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
In a large provider organization with multiple practice/administration/billing sites, it is often difficult to process refund request letters from the payers in time. A number of times, the letter is received and processed but the payer either does not get the refund check processed in time or refund check does not get posted to the individual claims in the adjudication system or both. As a result the payer does a take back of the refund owed and provider gets a double whammy.

Is it possible to use the 835 (which usually is from payer to provider) by the provider to send money back to the payer for such refund requests? The guide mentions the stakeholders that does not include providers but the list also states "not limited to".

There are many advantages to havning providers use this transaction if they wish to implement the "reverse 835":
-  By providing the payer claim ref# in the 835 and payer processing the 835, the individual accounts in the payer adjudication system would be adjusted saving payers a lot of human intervention to look at the check and related documentation and then go and adjust the accounts manually.
-  The process of 835 along with the EFT (or even a check) would cut down the time delay of mailing/receiving/ processing the refund check. 
-  This will also reduce PLB use in the 835 which is always a confusing and unclear process involving a lot of manual intervention requiring phone calls.

This whole issue of double whammy of refund/take-back is quite frustrating and costly to providers.

Please let me know if you need additional information.

Thank you.
Suggestion
Allow 835 to be used by provider to send money back to payer.
DSMO Category
D
Recommendation
Disapprove. The DSMO determined that there are other ways to handle auto-posting of the refund.  The DSMO invites the submitter to participate in X12N TG2/ WG3 Claim Payment discussions of solutions to this issue. It is noted that this request does not meet the HIPAA definition of the transaction. The TG2WG3 Claim Payments Co-Chairs are Patricia Wijtyk, wijtykP@Einstein.edu, Kim Peters, kpeters@humana.com, and Debra Strickland, dstrickland@foresightcorp.com.
Appeal Recommendation