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Back  RFI # 1137: COB balancing on 837s

Formal vs. Informal Help Informal Formal

Submitter

Craig Keene

Description

The 835 5010 TR3 states the SVC segment is required for professional, dental, outpatient claims priced at line level, and for inpatient claims when the room per diem is not the only service line adjustment. For 837I COB balancing, the claim payment =(line 1 payment + line 2 payment) – claim adjustment. For inpatient claims there are no line payments or adjustments on the 835. This will cause an out of balance condition to occur if the data is entered on the 837 as received on the 835. The example in the TR3 will balance for outpatient claims where there is line level data on the 835

80.00 = (70.00 + 15.00) – 5.00

But for inpatient claims it would look like:

80.00 = (0) – 5.00

Additionally, the example on page 35 in the TR3 is incorrect. The values used are not consistent. How can the claim adjustment (shown at $5) be $10 less than the sum of the line adjustments ($10 + $5)? This example is far more confusing than helpful. Please advise how to balance COB for institutional inpatient claims.

Submitter Assigned Keywords

COB Balance inpatient 837

Response

When a claim is adjudicated only at the claim level, the calculation expressed in section 1.4.4.1 would not be performed. The claim adjustment is not a sum of the line level adjustments. It is a separate adjustment only applied at the claim level. The ASC X12 TG2/WG2 will consider adding additional clarification in Section 1.4.4 for claims adjudicated at claim level only in a future version of the 837 TR3 to make it clear that this calculation only comes into play when there are line level payments/adjustments.

Recommendation

For balancing COB for institutional inpatient claims please refer to Section 1.10.2.1.2 (Claim Balancing) of the 835 5010X221 TR3.
Submission 8/23/2010
Status Date 9/24/2010
Status F - Final
Primary References
Document 005010X223
Section1.4.4
Page34
Set ID837I