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Back  RFI # 1596: Balancing multi benefit plans

Formal vs. Informal Help Informal Formal

Submitter

Stephanie Fetzer

Description

5010 HIPAA 837 Service Line Balancing question as a result of recent response to RFI 1508 et ux.

"Unbundled and split services will have two or more 2430 loops within one service line loop, all linked to the same payer by the SVD01. For each service line, the sum of the SVD02 payment amounts plus the CAS adjustment amounts in all 2430 loops for a single payer must add up to the charge in the SV102 for that service line. 2430 loops showing adjudication results of multiple previous payers must balance separately for each payer. Processing results from two separate benefit programs within the same payer are treated as separate payers for purposes of service line balancing and building the segments in the 2430 loops."

We were following along until the last sentence then we had a question. How do we unambiguously determine the presence of multiple benefit programs for the same payer (SVD01) for the purposes of service line balancing?

Submitter Assigned Keywords

5010 837 balancing payer multiple benefit programs

Response

ASC X12 TG2 WG2 recognizes that in situations where the subscriber may be covered under two policies with the same health plan that utilize the same payer id, there is no current way to link the line item COB information to the correct payer and there currently is no known workaround for this issue. This gap has been addressed in the next published version of the 837 TR3s.
Submission 5/25/2012
Status Date 6/29/2012
Status F - Final
Primary References
Document 005010X222
Section1.4.4.2
Pagen/a