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Back  RFI # 276: Corrected Claim/Total Charges

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Submitter

Oliver Smith

Description

An xx7 TOB with proper coding to indicate a change in total charges was submitted to our state Blue Cross agency. The CLP03 element in the resulting 835 contains the uncorrected charges from the original xx1 claim. The claim payment and adjustments have changed to reflect the revised total charges on the xx7 claim. The payment and adjustments do not equal the charges submitted on the xx7 claim. The payer inserts an adjustment code of 94 and assigns an amount equal to the difference in the total charges between the xx1 and xx7 claims to make the transaction balance. Should CLP03 reflect the charges we submitted on our xx7 claim thereby eliminating the need for the '94' adjustment to balance?

Response

The CLP03 must report back the total charge amount submitted by the provider to the payer for that specific claim. If a corrected claim was later submitted with a revised total charge amount, the CLP03 should report the total charge amount on the subsequent claim, not the first claim that was filed.
Submission 6/24/2005
Status Date 9/16/2005
Status F - Final
Primary References
Document 004010X091A1
Section2.2.8
Page28
Set ID835