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Back  RFI # 202: 837 - COB Ex: Error - Amt Paid

Formal vs. Informal Help Informal Formal

Submitter

Ryan White

Description

Example 3.A and 3.B in the 837-P Combined IG walks through an example of a provider-to-payer COB example in which 3 transactions are generated. First, an 837 to Payer A, then an 835 from Payer A, then an 837 to Payer B.

I believe there is an error in the 837 to Payer B when attempting to show the amount that Payer A has already paid on the entire claim.

The 835 shows a payment of $39.15 from Payer A. That number is correct and balanced and can be reached in a number of ways. For example:
$40 (Paid on Line 1) +
$15 (Paid on Line 2) +
$21.04 (Paid on Line 3) -
$21.89 (Patient Resp. Claim-Level Adjustment) -
$15 (Patient Resp. Claim-Level Adjustment) =
-------
$39.15

The second 837 shows an 'AMT - Payer Paid' segment value of $42.15. Why isn't this simply $39.15?

It seems as though the $3 contractual service level adjustment on line 1 was included in the 'AMT - Payer Paid' value. Please provide your interpretation of whether this is correct.

Thanks!
Ryan

Submitter Assigned Keywords

COB Payer Paid Error Example AMT

Response

The example is incorrect. The 2320 Prior paid amount is incorrect. It should be 39.15. We will be updating and correcting the example in its entirety in the 5010 version of the Implementation Guides.

Recommendation

Note - this response was modified on 5/19/2008 to correct the reported prior paid amount. The response now contains the correct amount.
Submission 2/9/2005
Status Date 4/1/2005
Status F - Final
Primary References
Document 004010X098A1
Section4
Page570
Set ID?
Table2
Loop2320
Segment IDAMT
Element Position02
Industry NamePayer Paid Amount