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Back  RFI # 137: 835 v4010A1 claim vs. line

Formal vs. Informal Help Informal Formal

Submitter

Cynthia Garrett

Description

The looping structure in the 835 v4010A1 Imp Guide states that the 2110 Loop, is subordinate to the 2100 Loop, which begins with the CLP segment. The note on CLP04 (Claim Payment Amount) states, "Use this monetary amount for the amount paid for this claim." If the payer either distinguishes each claim/service line as an individual “claim” and adjudicates accordingly or at the full claim level, does this represent the intent of the note?

Submitter Assigned Keywords

Use this monetary amount for the amount paid for this claim

Response

This issue is explicitly answered in guide X091 in section 2.2.11 on page 33. The payer can split a multiple service line claim into separate claims - even one claim per service - for adjudication. The section identifies the requirements on the payer when splitting claims.
Submission 11/11/2004
Status Date 11/15/2004
Status F - Final
Primary References
Document 004010X091
Section3.1
Page91
Set ID835