| Insurance payments (with EOB) |
Payment and remittance information for claims submitted. The common and primary type of content for the majority of 835 files received by Payers. |
Yes |
| Capitation payments |
The 835 is used to provide financial notification of capitation payments from a Managed Care Organization (MCO) to a capitated care provider. The 835 does not contain the capitation details or membership roster. |
Yes |
| Predetermination responses |
Information about future remittances that are to be paid when specified services are completed. |
Yes |
| Reversals and Corrections |
When the claim adjudication results have been modified from previous reporting, the method for revision is to reverse the entire claim and resend modified data.
|
Yes |
| Claim Splitting |
A claim submitted to a payer may, due to a payer's adjudication system, have service line(s) separated from the original claim. The commonly used term for this process is 'splitting the claim'.
|
No |
| Balance Forward Processing |
While the reversal and correction process identifies the process for reporting these changes, one aspect has been left out. Since the 835 is a financial transaction and not just a report, the payment amount cannot be negative. The question then arises, what do you do when refunds from reversals and corrections exceed the payments for new claims, resulting in a net negative payment? The answer is Balance Forward Processing.
|
Yes |
| Interest and Discounts |
Payer-provider level interest and prompt payment discounts refer to adjustments that specific payer and provider contractual agreements or regulations require.
|
Yes |
| Service Line Splitting |
During the adjudication process there may be times when a service line needs to be split.
|
No |
| Bundling / Unbundling |
Procedure code bundling or unbundling occurs when a payer believes that the actual services performed and reported for a claim payment can be represented by a different group of procedure codes.
|
No (reported) |
