CAS

Claim Adjustment

Pos: 295

Max: 5

Detail - Optional

Loop: 2320

Elements: 19


User Option (Usage): Situational
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Element Summary:

 

Ref

Id

Element Name

Req

Type

Min/Max

Usage

 

CAS01

1033

Claim Adjustment Group Code
Description: Code identifying the general category of payment adjustment

M

ID

1/2

Required

 

Code

Name

 

CO

Contractual Obligations

 

CR

Correction and Reversals

 

OA

Other adjustments

 

PI

Payor Initiated Reductions

 

PR

Patient Responsibility

 

CAS02

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-16.0, DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12. 0, DA3-14.0, DA3-16.0

M

ID

1/5

Required

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS03

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-09.0, DA1-10.0, DA1-11.0, DA1-12.0, DA1-13.0, DA1-30.0, DA1-33. 0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0

M

R

1/18

Required

 

CAS04

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

O

R

1/15

Situational

 

CAS05

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-17.0, DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12. 0, DA3-14.0, DA3-16.0
Used as needed to show payer adjustments.

C

ID

1/5

Situational

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS06

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-30.0, DA1-33.0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13. 0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0
Used as needed to show payer adjustments.

C

R

1/18

Situational

 

CAS07

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

C

R

1/15

Situational

 

CAS08

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-18.0, DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12. 0, DA3-14.0, DA3-16.0
Used as needed to show payer adjustments.

C

ID

1/5

Situational

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS09

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-30.0, DA1-33.0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13. 0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0
Used as needed to show payer adjustments.

C

R

1/18

Situational

 

CAS10

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

C

R

1/15

Situational

 

CAS11

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14. 0, DA3-16.0
Used as needed to show payer adjustments.

C

ID

1/5

Situational

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS12

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-30.0, DA1-33.0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13. 0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0
Used as needed to show payer adjustments.

C

R

1/18

Situational

 

CAS13

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

C

R

1/15

Situational

 

CAS14

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14. 0, DA3-16.0
Used as needed to show payer adjustments.

C

ID

1/5

Situational

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS15

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-30.0, DA1-33.0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13. 0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0
Used as needed to show payer adjustments.

C

R

1/18

Situational

 

CAS16

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

C

R

1/15

Situational

 

CAS17

1034

Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA1-30.0, DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14. 0, DA3-16.0
Used as needed to show payer adjustments.

C

ID

1/5

Situational

 

ExternalCodeList

 

Name: 139

 

Description: Claim Adjustment Reason Code

 

CAS18

782

Monetary Amount
Description: Monetary amount
Industry: Adjustment Amount
NSF Reference: DA1-30.0, DA1-33.0, DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13. 0, DA3-15.0, DA3-17.0, DA3-25.0, DA3-26.0
Used as needed to show payer adjustments.

C

R

1/18

Situational

 

CAS19

380

Quantity
Description: Numeric value of quantity
Industry: Adjustment Quantity
Used as needed to show payer adjustments.

C

R

1/15

Situational


Syntax:

1.

L050607 - If CAS05 is present, then at least one of CAS06,CAS07 is required

2.

C0605 - If CAS06 is present, then all of CAS05 are required

3.

C0705 - If CAS07 is present, then all of CAS05 are required

4.

L080910 - If CAS08 is present, then at least one of CAS09,CAS10 is required

5.

C0908 - If CAS09 is present, then all of CAS08 are required

6.

C1008 - If CAS10 is present, then all of CAS08 are required

7.

L111213 - If CAS11 is present, then at least one of CAS12,CAS13 is required

8.

C1211 - If CAS12 is present, then all of CAS11 are required

9.

C1311 - If CAS13 is present, then all of CAS11 are required

10.

L141516 - If CAS14 is present, then at least one of CAS15,CAS16 is required

11.

C1514 - If CAS15 is present, then all of CAS14 are required

12.

C1614 - If CAS16 is present, then all of CAS14 are required

13.

L171819 - If CAS17 is present, then at least one of CAS18,CAS19 is required

14.

C1817 - If CAS18 is present, then all of CAS17 are required

15.

C1917 - If CAS19 is present, then all of CAS17 are required

Semantics:

1.

CAS03 is the amount of adjustment.

2.

CAS04 is the units of service being adjusted.

3.

CAS06 is the amount of the adjustment.

4.

CAS07 is the units of service being adjusted.

5.

CAS09 is the amount of the adjustment.

6.

CAS10 is the units of service being adjusted.

7.

CAS12 is the amount of the adjustment.

8.

CAS13 is the units of service being adjusted.

9.

CAS15 is the amount of the adjustment.

10.

CAS16 is the units of service being adjusted.

11.

CAS18 is the amount of the adjustment.

12.

CAS19 is the units of service being adjusted.

Comments:

1.

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid.

2.

When the submitted charges are paid in full, the value for CAS03 should be zero.


Notes:

1. Submitters should use the CAS segment to report claim level adjustments from prior payers that cause the amount paid to differ from the amount originally charged.
2. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
3. Codes and associated amounts should come from the 835s (Remittance Advice) received on the claim. If no previous payments have been made, omit this segment. See the 835 for definitions of the group codes (CAS01).
4. Required if the claim has been adjudicated by payer identified in this loop and has claim level adjustment information.
5. To locate the claim adjustment reason codes that are used in CAS02, 05, 08, 11, 14 and 17 see the Washington Publishing Company website: http://www.wpc-edi.com. Follow the buttons to Code Lists -Claim Adjustment Reason Codes.
6. There are several NSF fields which are not directly crosswalked from the 837 to NSF, particularly with respect to payer-to-payer COB situations. Below is a list of some of these NSF fields and some suggestions regarding how to handle them in the 837.
· ·· · Provider Adjustment Amt (DA3-25.0). This would equal the sum of all the adjustments amounts in CAS03, 06, 09, 12, 15 and 18 at both the claim and the line level. See the 835 for how to balance the CAS adjustments against the total billed amount.
· ·· · Beneficiary Liability Amt (FA0-53.0). This amount would equal the sum of all the adjustment amounts in the CAS03, 06, 09, 12, 15 and 18 at both the claim and the line level when CAS01 = PR (patient
responsibility).
· ·· · Amount Paid to Provider (DA1-33.0). This would be calculated through the use of the CAS codes. Please see the detail on the codes and the discussion of how to use them in the 835 implementation guide.
· ·· · Balance Bill Limit Charge (FA0-54.0). This would equal any CAS adjustment where CAS01 = CO and one of the adjustment reason code elements equaled “45".
· ·· · Beneficiary Adjustment Amt (DA3-26.0) Amount Paid to Beneficiary (DA1-30.0). The amount paid to the beneficiary is indicated by the use of CAS code ”100 - Payment made to patient/insured/responsible party".
· ·· · Original Paid Amount (DA3-28.0). The original paid amount can be calculated from the original claim by subtracting all claim adjustments carried in the claim and line level CAS from the original billed amount.

Example:

CAS*PR*1*793~
CAS*OA*93*15.06~


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