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Back  RFI # 1608: 835 inpatient line payments

Formal vs. Informal Help Informal Formal

Submitter

Doug Lichtman

Description

On inpatient claims Medicare's 835 shows each line as paid in full without adjustments, all adjustments appearing at the claim level.

The 835 TR3 states line info is required for outpatient//dental/professional claims "... or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments", and "if not required do not send". Isn't Medicare's 835 non-compliant in reporting line information when line payments equal line charges without adjustments?

Note that the paid-in-full lines on the 835 cause a conflict on provider-submitted Med Supp claims due to the TR3 requirement of the line-level AMT*EAF Remaining Patient Responsibility, which could only logically report $0 for lines paid in full (which is usually false). The AMT*EAF could be reported accurately at the claim level but the TR3 explciitly forbids it, so an inpatient Med Supp claim can never be both compliant and accurate.

Submitter Assigned Keywords

Medicare inpatient 835 line payments

Response

This is explicitly address in the 835 guide 005010x221 for the SVC segment TR3 note that says: "Required for all service lines in a professional, dental or outpatient claims... or whenever payment for any service line of the claim is different than the original submitted charges due to service specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send."

Therefore, if there are no service specific adjustments on an institutional inpatient claim, excluding room per diem, and the claim is not paid in full, then sending the 2110 loop is inconsistent with the implementation guide.
Submission 6/18/2012
Status Date 8/10/2012
Status F - Final
Primary References
Document 005010X221
Section2.4
Page186
Table2
Loop2110
Segment Position0700
Segment IDSVC