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Back  RFI # 1772: 837I SV2 # of service lines

Formal vs. Informal Help Informal Formal

Submitter

Teresa Yates

Description

I see the repeat loop for 2400 sv2 has a max of 999 lines. I am a provider that has a payer restricting the reporting of only 22 service lines. Can a payer force this restriction on all providers due to their system? Should they be compliant with the 999 as specified in the 837I transaction set specs?

Submitter Assigned Keywords

SV2, Number of Service Lines

Response

Guide 005010X223 explicitly allows the submission of up to 999 2400 loops per claim.

Supporting business reasons for complying with this up to 999 2400 loops per claim limit are:


1. Section 1.4.1.1 (Coordination of Benefits Data Models - Detail) identifies that the claim/service detail is not changed when sending a claim to subsequent payers. Only payer specific content is moved between sections and adjudication information is added. Therefore, assuming the payer processes COB claims, the payer should be accepting a COB claim that exceeds their 22 service line limit when sent.

2. Guide 005010X221 (Health Care Claim Payment/Advice) section 1.10.2.11 (Claim Splitting) describes how a health plan may split an incoming claim into multiple claims. This process allows a health plan to receive a single claim with, for example - 50 service lines, and split that into multiple claims, for example 2 claims of 22 service lines and 1 claim of 6 service lines. So, if the payer can only adjudicate a subset of the 999 service lines (22 as indicated by the RFI submitter) a compliant approach is available.
(response continued in Recommendation)

Recommendation

(Response continued)
For these reasons, restricting the number of services lines that can be submitted by a provider to different than the up to 999 2400 loops is inconsistent with the COB requirements as well as being unnecessary due to the claim splitting process.

If the 837I transaction is being used in a HIPAA-covered environment, federal HIPAA regulations included in Title 45, Parts 160 and 162 (45 CFR 160 and 45 CFR 162) may impose additional or different constraints. This response does not address any potential HIPAA constraints, which must be addressed by CMS' Office of E-Health Standards and Services (CMS/OESS).
Submission 4/4/2013
Status Date 5/8/2013
Status F - Final
Primary References
Document 005010X223
Section2.4
Page424
Table2
Loop2400
Segment IDsv2