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Back  RFI # 482: CLP05 Balancing

Formal vs. Informal Help Informal Formal

Submitter

Danielle Marquez

Description

Page 91 of the HIPAA Implementation Guide states; ÔÇťAmounts in CLP05 should have supporting adjustments of the patient reflected in CAS segments at the CLP of SVC loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). In the examples below the payer has the supporting CAS*PR segment, but are not reflecting the Patient Responsibility amount in CLP05. Is it mandatory that the CLP05 be populated when CAS*PR segments are present? This is for BC 835 data.


CLP*######*1*155*82.5**MC*20629951001008705*12~
NM1*QC*1*#####*#####****MI*########~
NM1*82*2*#######*****MC*########~
DTM*050*20061026~
DTM*232*20061010~
DTM*233*20061010~
SVC*HC:90806*155*82.5**1**1~
DTM*472*20061010~
CAS*PR*3*2~ <-- HERE
CAS*CO*42*70.5~
REF*SY*522125435~
LX*192~

Response

This issue is explicitly addressed in guide 004010X091. The implementation second note on element CLP05 state "This amount must be entered if it is greater than zero." The presence of a CAS segment with a CAS01 of PR (Patient Responsibility) and a CAS03 value greater than zero means that the Patient Responsibility Amount IS greater than zero. Therefore, CLP05 must be entered.
Submission 11/9/2006
Status Date 11/14/2006
Status F - Final
Primary References
Document 004010x091A1
Section835-2100
Page91
Set IDCLP05
Loop2100
Segment Position010
Segment IDCLP
Element Position05