2100 Claim Level Reason Codes

This section provides additional information on Claim Level reason codes that are returned in the ERA 835 file at the 2100 Claim Level. Settings in the Remittance Profiles Library and the Reason Codes Library work together to determine how these claim level codes are handled when the ERA file is imported and processed in NextGen® Enterprise PM.

For example, when a denial code is returned at the 2100 claim level, it may be desirable to post the transaction to line items on the encounter with a status of Appeal so charge balances remain in the current payer bucket in Balance Control without moving to the subsequent payer or patient bucket.

In the image below, code CO20 is setup in the Reason Codes library as a Claim Level code with a Transaction Detail Status of Appeal.

Upon ERA import, the Transaction Detail Status from the Reason Codes Library is applied to line items on the encounter, as determined by the Remittance Profile Library setting, and the transaction status follows standard functionality to handle the balance on those line items. (For example, Appeal, Deny or None result in the balance remaining in the current COB bucket.)

If Skip ERA Adjustment is selected for the claim level code in the Reason Codes Library, the adjustment amount will not be applied to line items, regardless of the setting in the Remittance Profiles Library.

If no Transaction Detail Status is attached to the claim level code in the Reason Codes Library, balances on line items, as determined by the Remittance Profiles Library setting, will settle to the subsequent payer COB or patient bucket in Balance Control.

The above functionality also applies to secondary and tertiary payer claim level codes if the Process Secondary Adjustments and/or Process Tertiary Adjustments options are enabled in the Remittance Profiles Library.

If more than one claim level code is returned in the CAS segment (2100-CAS), the Transaction Detail Status attached to the claim level code that ranks highest in the Reason Code Priority list will be used.

Transaction Detail Status for line items that were part of a split-bill claim is determined by the Enable Chart MRN for 2300 REF*EA setting for the payer on the Payer > System tab > Claims-2 sub-tab. The 2300-REF*EA segment (Other Claim Related Identification), controls what is sent in the REF02; either the patient’s Medical Record Number (MRN), or a claim specific Claim ID number.

• If this payer option is not selected (default), the 2300-REF*EA segment is used to identify charges on the original claim and the Transaction Detail Status is applied only to those charges that were included on the claim. This works for most payers and also accommodates split-bill claims where some line items on the encounter were billed to one payer, and other line items were billed to another payer (e.g. Medicare A/Medicare B).
• If this payer option is selected, the Transaction Detail Status for claim level codes is applied to all line items on the encounter.