Several Community Health Centers have requested that CHPW’s 835 files (electronic remittance advices) include the allowed amount on capitated claims. CHPW is pleased to announce that effective November 5, 2017 the 835s will include the allowed amount for capitated claims on the 835 files. With this enhancement, capitated claims will report the allowed amount in the X12 on two lines: one with the provider’s write-off amount, the other with the contractually allowed amount for the claim line.

Example: CLP*555555555*1*330*13.19**12*1709070AV0000000*11*1~

NM1*QC*1*SAMPLE*HAPPY****MI*1234567801~

NM1*82*1*TEST*PROVIDER*M***XX*5555555555~

REF*CE*HRSA~

DTM*232*20170830~

DTM*233*20170830~

DTM*050*20170907~

AMT*AU*330~

SVC*HC>99392*228*0**1~

DTM*472*20170830~

CAS*CO*24*140.54~ (this CAS segment reflects the difference between the billed amount and the allowed amount; this is the provider’s write-off amount)

CAS*OA*24*87.46~ (this new CAS segment reports the contractually allowed amount for the claim detail line)

Prior to the enhancement, the allowed amount was not provided in the X12; prior to the enhancement, the above payment looked like this: CLP*555555555*1*330*13.19**12*1709070AV0000000*11*1~

NM1*QC*1*SAMPLE*HAPPY****MI*1234567801~

NM1*82*1*TEST*PROVIDER*M***XX*5555555555~

REF*CE*HRSA~

DTM*232*20170830~

DTM*233*20170830~

DTM*050*20170907~

AMT*AU*330~

SVC*HC>99392*228*0**1~ ($228.00 is the total billed on the detail line)

DTM*472*20170830~

CAS*CO*24*228.00~ (the CAS segment reflects the same amount and indicates the line is capitated)

If you have any questions, please contact EDI.Support@chpw.org.