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Formal vs. Informal Help Informal Formal

Submitter

Ryan Wexler

Description

I am confused as to the relation of clp04 to svc03. I started questioning this in my inquiry #450 using the bundling example. I thought I understood the explanation I was given, but after looking at it some more I am confused. I always thought the svc payment amount was inclusive of the clp payment amount. In this example they are separate. The payer is telling us what they would pay in context of what is allowed, but I would much rather know what they actually paid. I thought the actual payment was the purpose of this value. I already know what is allowed based on the CO adjustment. So why supply the possible payment per the contract?

Most payers seem to follow the scheme I suggested. The SVC03 value is a portion of the CLP04. The balancing rules would be as follows:
The clp04 might exceed the sum of svc03, indicating a claim level payment. But the sum of the svc03 values should never exceed the clp04.

Other payers do not follow this logic. I am confused and would appreciate clarification.

Submitter Assigned Keywords

claim payment and service line payment balancing

Response

If there are not claim level (2100) adjustments, CLP04 will equal the sum of SVC03. However, if there is a combination of claim level AND service level adjustments, then the sum of SVC03 will not equal CLP04.
Submission 9/14/2006
Status Date 11/10/2006
Status F - Final
Primary References
Document 004010X091
Section2.2.6
Page26
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