RFI Browser

Back  RFI # 1053: 837 Professional Balancing

Formal vs. Informal Help Informal Formal

Submitter

Thomas Peterson

Description

I am trying to understand the new TR3 book for the 5010 X222 Professional Health Care Claim.

On pages 34-35 they try to explain balancing.

The example given on Page 35 has a total claim payment of 80.00.
There were two service lines.
Line 1 payment 70.00
Line 2 Payment 15.00

The total of the line payments is 85.00 yet the total claim payment is only 80.00.
They report a claim adjustment of 5.00 which is supposed to reduce the payment back to 80.00.

As a provider receiving the payment, if had sent the line item control number in loop 2400, this is going to be returned in the 835 transaction so I can apply the payments to my system.

How am I to apply the individual line payment amounts to my system when the sum of them do not add up to the total payment. (Line item payments = 85.00, claim payment = 80.00)

How do I know which line item needs to be adjusted by 5.00 to properly reflect the total payment received on my system?

Response

The Guide and the example accurately reflect a line level and claim level adjustment applied to the same claim. The 837 conforms to the functionality of the 835 which allows this in some circumstances. Refer to 835 TR3 for guidance on claim and line level adjustments. Please note, that professional claims are expected to be adjusted at the line level.

In the example, the line level adjustments of $10.00 and $5.00 could be a Co-Pay applied to the services. The $5.00 claim level adjustment could be a remaining deductible that is applied on a per claim basis. In this case, the receiver of the remittance would have to determine how to apply a claim level adjustment if they were accounting at the line level.

Please refer to Section 1.4.1.1.
Submission 5/20/2010
Status Date 8/26/2010
Status F - Final
Primary References
Document 005010X222
Section1.4.4.2
Page35
Set IDunknow