Stream: CARIN IG for Blue Button®
Topic: Capitated Claims
Henry Perretta (Mar 08 2021 at 01:53):
Hello - I've had the following working assumption: if you have a claim in your system that was processed as a capitated claim by the payor - then any fields related to "costs borne by the payer" could be sent (per the CARIN BB IG) as $0. Basically - does this reasoning align with others? I know there is the concept of so-called "shadow costs" (that is: conveying what WOULD have been the cost paid to the member or provider IF the clam was fee-for-service" - but I'm thinking that it would be equally legitimate to send $0 via the API. Example: say a provider is paid a Per Member Per Month capitation fee to cover all services. However the payer contractually obligates the provider to file a "zero pay claim" for each provider/patient encounter. The resulting claim is not paid by the payor - but the data is essentially the same as if it were a claim to be paid.
Last updated: Apr 12 2022 at 19:14 UTC
