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Back  RFI # 522: 835 Balances and impact on COB

Formal vs. Informal Help Informal Formal

Submitter

Sou Chon Young

Description

The ASC X12N 835 (004010X091) IG states in section 2.2.1 the "amounts reported in the 835, if present, MUST balance at three different levels
— the service line, the claim, and the transaction."

The issue is a major payer is currently adjudicating at the cliam level. But at the line level they are sending back SVC02=SVC03 and then off-set it at the claim level with a claim adjustment amount (CAS). So the sum of SVC03s plus CAS segment equals CLP04. Is this compliant?

The impact is when we (provider) take the remittance advice information to create our COB claims it is causing balancing issues.

Can X12 give some guidance/restriction on not sending line level remittance information, if adjudicating at the claim level?

Submitter Assigned Keywords

835 info impacting COB claims

Response

This issue is technically addressed in guide 004010X091. Section 2.2.1 states that CLP03 minus the CAS dollar amounts must equal CLP04.
Based upon your description, that is happening. Section 2.2.4.1 provides direction for reporting claim level adjudication related to inpatient institutional claims.

Section 2.2.1 also states "Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim." The operative there is "service
payment information", not just services (SVC segment).

In this scenario, there do not appear to be any payment adjustments specific to the line items, so they appear to be paid in full and the claim level adjustment applies to the entire claim. It would be appropriate to not report the service lines and any related details.
Submission 2/22/2007
Status Date 5/7/2007
Status F - Final
Primary References
Document 004010X091
SectionDetail
Page19
Set IDSVC
Table2
Loop2110
Segment Position070
Segment IDSVC
Element Position03
Industry NameLine Item Provider Payer Amount