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Back  RFI # 1839: Section 1.10.2.18 Totals withi

Formal vs. Informal Help Informal Formal

Submitter

Gary Beatty

Description

In 005010X221, Section 1.10.2.18 there is a reference to TS304 in the second paragraph that refers to the total number of claims for a 2000 loop (and the total claim charge in TS305).

In the same Section it refers to other totals that can be calculated including "Total Number of Claims" (count of the number of CLP segments in the 835) and "Total Claim Charge" (sum of the CLP03 values in the 835).

How do these caluculated values differ from the values in TS304 and TS305 respectively from paragraph 2? Does one of these totals include duplicate claims (e.g. corrections/reversals - Section 1.10.2.8) where you may have more than 1 CLP for the same patient control number?

When we only count unique claims in loop 2100 for TS304 we get the following message from our compliance tool:

The Total Claim Count in the Summary Information (TS3-04) must equal the actual number of Claims in this Loop 2000 in this Remittance Advice (Count of CLP segments).

Clarification in the next guide would be helpful.

Submitter Assigned Keywords

835 TS304 Total within the 835

Response

Guide 005010X221 doesn't provide explicit instructions as to how to calculate the values for TS304 and TS305. There is no statement on whether this is the total of the unique claims (excluding any reversals or duplicate claims) or the total including reversals in the TS3 segment instructions.

Since the TS3 segment itself is situational and may not be present, the guide included examples of how to calculate certain totals that could be found in the TS3 segment, when not present, in section 1.10.2.18. The section 1.10.2.18 totals are for the entire 835, while the TS3 totals are for a specific iteration of the 2000 loop. That section identifies the Total Claim Charge as the sum of all CLP03 values, and the Total Number of Claims as the count of the number of CLP segments in the 835. TS304 has an implementation name of "Total Claim Count". TS305 has an implementation name of "Total Claim Charge Amount".

Therefore, the concept of a unique claim or the exclusion of any reversal claims from the calculation of the TS304 and TS305 values is inappropriate. The claim count is the count of all related CLP segments (entire 835 or single 2000 loop), and the total claim charge is the sum of the related CLP03 values.

Clarification will be considered for the next guide.
Submission 8/5/2013
Status Date 8/30/2013
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1