Change Request Detail
No.
802
Date
4/9/2003
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
The claim adjustment codes specified in the 835 standard (loop 2100 at claim level and loop 2110 at service level - CAS segment) are not specific enough for payors to communicate the true rejection/denial reason to the providers. Multiple payor proprietary codes that represent variety of reasons map to the same generic HIPAA code(s). As a result, providers impacted by this situation have no other means to decipher the underlying rejection without initiating a phone call or tediously referencing a paper EOB (if available).
Suggestion
All payors MUST report appropriate segment MIA (Medicare Inpatient Adjudication) or segment MOA (Medicare Outpatient Adjudication) at the claim level in loop 2100 or an LQ segment at the service level in loop 2110 if there exists a CAS segment with a claim adjustment code.

If appropriate crosswalk between the payor proprietary claim adjustment code and HIPAA standard claim adjustment code does not exist, the payors should be allowed to report their proprietary code in the remark-code field in appropriate segments on the interim basis. There should also be a new field added to the MIA, MOA and LQ segments to identify whether the code reported in the segment is standard code or proprietary code. The payors should then be required to request additional remark code(s) from CMS via the Washington Publishing Company web page remark code request function per CMS guidelines.
DSMO Category
D
Recommendation
Disapprove. This request should be directed to the Claim Adjustment Reason Code Committee or the HHS Remark Committee.  In addition, providers should ask the payers to supply them with an appropriate mapping, if available, of their proprietary codes to the HIPAA standard codes.  Information is available at www.wpc-edi.com/codes.
Appeal Recommendation