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Back  RFI # 1855: 835 paid units SVC05

Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

The response to RFI 386 states that SVC05 represents "paid units of service". The response also indicates that when a line has been denied (zero amount paid), the paid units value must also be zero. Based on this RFI response and the rules in the TR3, is the following "rule" accurate?
When SVC03 Line Item Provider Payment Amount is zero, then SVC05 Units of Service Paid Count must be zero

If so, would this rule apply universally under the conditions below?
Service line zero amount paid based on:
Duplicate
Non-compensability
Deductible
Benefit limits exhausted
Co-pay

If the SVC05 represents the actual paid units does this mean that there is no element to report the adjudicated units?
In cases where the line paid amount represents a portion of a whole unit (e.g. deductible, limit exhausted) should a partial paid unit be reported if a whole unit was billed?

Submitter Assigned Keywords

835 svc05

Response

The response to RFI 386 does not say that when the SVC03 =0 then the SVC05 = 0. The answer was accurate for the business situation that was presented.

For your requested business scenarios this general principle guidance should help you to determine if you need to present adjusted units.

SVC05 is the sum of the original submitted provider units that are considered for payment under the benefit provisions of the health plan (covered). This excludes units considered not covered (e.g. duplicate submissions, visits) but includes reductions to payments of covered services (e.g. reductions for amounts over fee schedule and patient deductibles). SVC07 is the original submitted units.

When the unit count is not an influencing factor in the adjudication outcome for the line, and the service is either partially or fully covered, the units are generally not adjusted and the original submitted units would be placed in the SVC05 element.
Submission 9/20/2013
Status Date 11/12/2013
Status F - Final
Primary References
Document 005010x221A1
Section2.4
Set ID835
Table2
Loop2110
Segment Position0700
Segment IDSVC