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Back  RFI # 2287: BPR-02 vs. Actual Deposit Amt

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

In the 835 transaction (005010X221), is is permissible for the amount sent in the BPR-02 todiffer from the actual amount deposited into the provider's bank account? We have seen a payer routinely omit claims from 835s that were not submitted electronically. Payments for these 1500-form claim submissions are included in EOBs and bank deposits for a payer-issued check, but not in the 835 with the same check number.
Example: 7 claims in an 835. 9 claims in the EOB (and 9 claims paid in the bank deposit).

Response

This issue is explicitly addressed in the 005010X221A1 TR3.

According to the X12 835 TR3, the total amount of payment deposited to the provider’s account in the health care EFT or check must equal the total amount of payment indicated on an associated ERA. If payment is being made for claims (whether submitted electronically or on paper) with a single payment device (check or EFT), the corresponding 835 must reflect that entire payment amount, and must include the detail for all claims included in the payment in order to balance.

The Implementation Name for BPR02 is: Total Actual Provider Payment Amount. This means that BPR02 contains the actual amount paid to the provider and deposited in their account, either by check or EFT, using the mechanism indicated in BPR04, and Trace Number indicated in TRN02.

The note on BPR02 includes: “Use BPR02 for the total payment amount for this 835.”

The Implementation Name for TRN02 is Check or EFT Trace Number, and theTRN02 element note includes: “If payment is made by check, this must be the check number.”

These items work together for the provider to reassociate the payment to the 835. The payment amount in BPR02 for the payment device indicated in TRN02 must match between the 835 and the provider’s account for the provider to reassociate the information. There must be a one to one relationship between the payment and the 835 transaction. The 835 Technical Report Type 3 (TR3) contains multiple references to the fact that there is a one to one relationship between the payment and the 835 transaction set.

The following sections from the ASC X12 005010x221A1 835 TR3 clearly reference the requirement regarding this relationship:

1.10.1.1 Payment
One 835 transaction set reflects a single payment device. In other words, one 835 corresponds to one check or one EFT payment. Multiple claims can be referenced within one 835.

1.10.1.4 Remittance

The 835 must be balanced whenever remittance information is included in an 835 transaction. For a balanced 835, the total payment must agree with the remittance information detailing that payment. The remittance information must also reflect an internal numeric consistency.

1.10.2.2 Remittance Tracking

NOTE
Due to the need for remittance tracking, there is a one to one relationship between any specific 835 and the related payment mechanism (check or EFT). One 835 must only relate to a single payment mechanism and one payment mechanism must only relate to a single 835. The only exception is a non-payment 835 (BPR02=0) where there is no associated payment mechanism.

TRN – Re-association Trace Number Segment ASC X12 835 5010x221 TR3
TR3 Note: This segment’s purpose is to uniquely identify this transaction set and to aid in re-associating payments and remittances that have been separated.

TRN02 Element Note: This number must be unique within the sender/receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a nonpayment 835, this must be a unique remittance advice identification number.

Please also see RFI #2075
Submission 5/8/2018
Status Date 6/28/2018
Status F - Final
Primary References
Document 005010X221
Section1.10.2.3