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Back  RFI # 1764: 835 - Alternate Benefit Paid

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Submitter

Judith Pasick

Description

Need 835 example for alternate benefit on a dental claim.
submitted claim detail:
svc1 procedure code D0120 chrg amt 60.00 pd amt 25.00
svc2 procedure code D1120 chrg amt 70.00 pd amt 44.00
svc3 procedure code D1203 chrg amt 40.00 pd amt 27.00
svc4 procedure code D0220 chrg amt 30.00 pd amt 0 denied
svc5 procedure code D0230 chrg amt 25.00 pd amt 0 denied
svc6 procedure code D0330 chrg amt 120.00 0 denied
alternate benefit paid code D0210 75.00 paid (fee of 175.00)
Is the below segment usage correct?
AMT*AU*171
SVC*AD:D0120*60*25**0
DTM*472*20121219
CAS*CO*A2*35
SVC*AD:D1120*70*44**0
DTM*472*20121219
CAS*CO*A2*26
SVC*AD:D1203*40*27**0
DTM*472*20121219
CAS*CO*A2*13
SVC*AD:D0210*30*75**0*AD:D0220
DTM*472*20121219
CAS*CO*A2*100
CAS*OA*94*-145
SVC*AD:D0210*25*0***AD:D0230
DTM*472*20121219
CAS*CO*97*25
SVC*AD:D0210*120*0***AD:D0330
DTM*472*20121219
CAS*CO*97*120

Response

Here is the analysis of your segment usage:

1 - SVC05 is reporting 0 paid units when there is a payment on the service. This should be reporting 1 unit (assuming that the submitted units is 1) (note - default for SVC05 is 1 when not present). For the lines not paying anything, SVC05 is empty, indicating one paid unit, which is not accurate. Those services should show SVC05=0, and SVC07 (submitted units) as 1.

2 - Reductions to the allowed amount seem to be reported using CAS*OA*A2, when it must be CAS*CO*45. (CARC A2 was stop dated in 2007)

3 - Since there is a payment on many lines, lines with a payment should be reporting an AMT*B6... with the allowed amount.

4 - The alternate benefit represents the bundling of the 4th, 5th and 6th services into the alternate code, and is accurately identifying the adjudicated code and submitted code and directly related adjustments (except as identified in #2).

5 - Since no lines were actually not covered, the Coverage Amount should be 345.



(The date is reported at the claim level since all services have the same date. Both levels can be reported)

(see Recommendation for the rest of the response)

Recommendation

The segments should look like:

DTM*232*20121219
AMT*AU*345
SVC*AD:D0120*60*25
CAS*CO*45*35
SVC*AD:D1120*70*44
CAS*CO*45*26
SVC*AD:D1203*40*27
CAS*CO*45*13
SVC*AD:D0210*30*75***AD:D0220
CAS*CO*45*100
CAS*OA*94*-145
SVC*AD:D0210*25*0**0*AD:D0230*1
CAS*CO*97*25
SVC*AD:D0210*120*0**0*AD:D0330*1
CAS*CO*97*120
Submission 3/14/2013
Status Date 4/19/2013
Status F - Final
Primary References
Document 005010X221
Section2.4