RFI Browser

Back  RFI # 1294: 837I 5010 COB Claim Balancing

Formal vs. Informal Help Informal Formal

Submitter

Kenneth Greenspan

Description

I am unclear on how to interpret this language from the 837I 5010 TR3, section 1.4.4.1: "Expressed as a calculation for given payer: {Loop ID-2320 AMT02 payer payment} = {sum of Loop ID-2430 SVD02 payment amounts} minus {sum of Loop ID-2320 CAS adjustment amounts}."

Suppose I have this data for loop 2320 & no 2430 loop:
SBR*S*01*GR1234567******BL~
CAS*CO*45*5000~
CAS*PR*1*4000~
AMT*D*1000~

Since there is no 2430 loop present, would the balancing be: 1000 = 0 - (5000 + 4000)? This would be false, which makes this 837I non-compliant, correct? The "0" above is since 2430/SVD02 is not present. Had AMT02 = -9000, it would be compliant. Is this correct?

Also, from HIR# 1115, is the balancing correct:
2300 clm_02 = 2320 AMT*D + sum of CAS adjustments in CAS_03,06,09,12,15,18?

Submitter Assigned Keywords

COB 2320 CAS

Response

The claim level COB calculation reflected in section 1.4.4.1 bullet 2 would only be performed when line level payment information exists. When line level payment information does not apply, there is no claim level COB balancing required for the claim.

There are two balancing calculations for the total claim charge amount (CLM02).
1) CLM02 = Sum of all service line charge amounts
2) CLM02 = the claim level prior payer paid amount + all claim adjustment amounts (CAS) at both the claim and service line (2320 and 2430)
Submission 4/6/2011
Status Date 6/1/2011
Status F - Final
Primary References
Document 005010X223
Section1.4.4.1
Page34
Set ID?