More Information
Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.
Answers to the following questions are available by clicking the question
• What is a Claim Adjustment Group Code?
• What do the Start, Last Modified, and Stop dates mean?
• Where are they used?
• How are they maintained?
• Who maintains the list?
• Where are the committee's minutes?
• How do I request a change?
• How do I monitor my change request?
• Are there other FAQs?
Explanation of Claim Adjustment Group Codes
- CO - Contractual Obligations
This group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write off for the provider and are not billed to the patient.
- CR - Corrections and Reversals
This group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim. When correcting a prior claim, CLP02 (claim status code) needs to be 22. See ASC X12N Health Care Claim Payment/Advice Implementation Guide (835) section 2.2.8 for complete information about corrections and reversals.
- OA - Other Adjustments
This group code should be used when no other group code applies to the adjustment.
- PI - Payer Initiated Reductions
This group code should be used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).
- PR - Patient Responsibility
This group should be used when the adjustment represent an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.
Explanation of Start, Last Modified, and Stop
- Start
Every code has a Start date. This is the date when the code was first available in the code list.
- Last Modified
When populated, this is the date of the code list release when the definition of the specific code was last modified by the committee. This date represents a point when the definition changed from one wording to another.
- Stop
When populated, this date identifies that the code can no longer be used in original business messages after that date. The code can only be used in derivative business messages (messages where the code is being reported from the original business message). For example, a Claim Adjustment Reason Code with a Stop date of 02/01/2007 would not be able to be used by a health plan in a CAS segment in a claim payment/remittance advice transaction (835) dated after 02/01/2007 as part of an original claim adjudication (CLP02 values like “1", ”2", “3" or ”19"). The code would still be able to be used after 02/01/2007 in derivative transactions, as long as the original usage was prior to 02/01/2007. Derivative transactions include: secondary or tertiary claims (837) from the provider or health plan to a secondary or tertiary health plan, an 835 from the original health plan to the provider as a reversal of the original adjudication (CLP02 value “22”). The deactivated code is usable in these derivative transactions because they are reporting on the valid usage (pre-deactivation) of the code in a previously generated 835 transaction.
004010X091 - Health Care Claim Payment/Advice (835)
Table 2, CAS segment at positions 020 & 090, in elements 02, 05, 08, 11, 14 & 17. Each element is qualifed by the Claim Adjustment Group code carried in CAS01.
See the following sections of the Implementation Guide for information- 2.2.1
Balancing - 2.2.4
Claim Adjustment and Service Adjustment Segment Theory - 3.1
CAS Segment detail
004010X096, 004010X097, 004010X098 - Health Care Claim: Professional, Institutional and Dental Guides
Table 2, CAS segment at positions 295 and 545, in elements 02, 05, 08, 11, 14 & 17.
See the following sections of the Implementation Guide for information- 1.4.2.2
Coordination of Benefits Data Models Detail - 3.1
CAS Segment detail (pages vary in each guide)
The Claim Adjustment Status Code maintenance committee meets on the Sunday of each ASC X12 trimester meeting. The meetings are held three times a year:
The Claim Adjustment Status Code Maintenance Committee
The Claim Adjustment & Status Code Maintenance Committee Meeting Minutes
It is recommended that individuals pursuing a new code or changes to a code message first contact their industry representative on the committee or another committee member by email to discuss their request prior to submitting the form.
By doing so, this may facilitate their request by allowing someone familiar with the approval process to discuss an alternate solution (if appropriate) for their need, or enabling that committee member to obtain additional background information which could help with the request.
Requestors are not required to contact a committee member prior to submitting their request, but they are strongly encouraged to do so. This process allows the committee to more fully understand and discuss requests and have more time at the meeting to do so.
Click the Change Requst Form link above to request a change or a new code.
Use the On-Line Conference to participate in the discussions concerning code maintenance.
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