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Back  RFI # 2204: CLM02 Total Claim Charge Amt

Formal vs. Informal Help Informal Formal

Submitter

Betty Westbrook

Description

In Section "B.1.1.3.1.2 Decimal" of the 837P X12 Implementation Guide, it states that "decimal data elements in Data Element 782 (Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents".

In the CMS 837P Companion Guide (https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/downloads/5010A1837BCG.pdf), on pg. 6 it states "The maximum number of characters to be submitted in any dollar amount field is seven characters. Claims containing a dollar amount in excess of 99,999.99 will be rejected." This is also reiterated in the 837P CMS Edit X222.157.2300.CLM02.050, which states "2300.CLM02 must be >= 0 and <= 99,999.99."

A MAC is rejecting a claim that has total charges of over 100,000.00 (ex. 123,456.78) because it is over 99,999.99. Per X12 this dollar amount would be compliant for that field since it has 8 characters and is less than the 10 character maximum. The MAC is stating that X12 only dictates what the maximum character limit is for that field, but that CMS can require it be less than that as a "business exception". Are they compliant in this practice?

Submitter Assigned Keywords

837P CLM02 Total Claim Charge Amount/Monetary Amount

Response

It is correct that a value of 100000.00 in the CLM02 is compliant with the 005010X222A1 837 Professional TR3. ASC X12 does not govern the receiver’s action related to the acceptance or rejection of a transaction that is either compliant or non-compliant with a specified ASC X12 TR3. A receiver’s action is based on its business process and any applicable regulations.
Submission 3/14/2017
Status Date 4/25/2017
Status F - Final
Primary References
Document 005010X222
Section2.4