RFI Browser

Back  RFI # 680: ERA - CLP05 balancing

Formal vs. Informal Help Informal Formal

Submitter

Ellen Falbowski

Description

I found an ERA claim which has a CASR*PR*3*5 (pat resp co-pay = $5) and the CLP05 is not valued. I would have expected the CLP05 to also have a value of 5 (pat resp = $5), and I was wondering whether, in your opinion, this is a balancing error.

The 4010 IG is not as clear on this point as I would like:

"Amounts in CLP05 should have supporting adjustments reflected in CAS segments at the CLP or SVC loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility).

"Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay, and co-insurance. This amount must be entered if it is greater than zero. See 2.2.1, Balancing, and 2.2.9, Interest and Prompt Payment Discounts, for additional information."

[Note: Neither 2.2.1 nor 2.2.9 discusses pat resp balancing.]

Submitter Assigned Keywords

CLP05 ERA balancing patient responsibility

Response

This issue is explicitly addressed in guide 004010X091. As stated, the note on CLP05 reads "This amount must be entered if it is greater than zero". By using a CAS*PR*3*5 without any PR related negative amounts to bring the PR statement to zero, the payer is stating that there is a patient responsibility. Therefore, CLP05 must be populated with that amount. This is not a balancing error since it isn't related to the Balancing section, however, it is an error in that the CAS message states that there is a patient responsibility, requiring that value in CLP05.
Submission 8/27/2008
Status Date 9/18/2008
Status F - Final
Primary References
Document 004010X091A1
SectionDETAIL
Page91
Set ID835
Table2
Loop2100
Segment Position010
Segment IDCLP
Element Position05
Industry NamePatient Responsibility Amount