Will 5010 Changes to the 835 Prove Helpful to Providers?

The 835 electronic remittance transaction has enormous potential to save administrative costs for both Payers and Providers. However, problems with the 4010A1 version have prevented providers from realizing the potential cost savings that could be made available through the automated posting of the remittance information.

Problems commonly reported by providers include:

Inaccurate reporting of bundling and split claims
Inconsistent use of Claim Adjustment Reason Codes and Group codes
Inaccurate reporting of corrections and reversals

So what, if any, changes have been made in the 5010 to mitigate these issues? It has been noted that the 5010 version of the 835 contains relatively few syntactical differences, but the addition of a critical new data element combined with some substantive Front Matter changes may offer providers the help they are looking for.

Key data change:
The addition of service line ID number (2110 REF*6R) - This is the Line Item Control Number submitted in the 837, and it is now required when sent in the original 837 or when claim or service line splitting has occurred.

New front matter directives:

Corrections and Reversals are now to be reported completely differently. The CR group code has been eliminated and reversals are now indicated by a CLP02 value of 22. The sign on the original adjustment amount must then be changed from reversed and associated with the original CARC and Group Code.
Additional detail on how to report partial bundling - additional data now required if partial bundling has been performed during adjudication
Additional detail on how to report split claims - clarification that all service lines submitted in the original 837 claim must be reported back on all 835’s related to that claim.
Additional clarity on using Remark codes in conjunction with Claim Adjustment Reason Codes.

It remains to be seen if these Front matter changes will be rigorously enforced in version 5010. If not, they may ultimately provide little or no help to providers trying to realize the advantages of "Administrative Simplification."

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Walter Dupree

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