I am currently working with a vendor on balancing the 835 as defined in the IG page 19-21.
It appears we have a difference in opinion as to what is balancing. They state that
lines balance and the claim balances, but they do not have to balance or cross foot to
each other.
Note the example below:
Simple example ...
3160 *CLP*018918525*1*97*53**15*13221979281508@
3161 CAS*OA*A1*22.08@
3162 NM1*QC*1*DROF*TREBOR****MI*525172765@
3163 NM1*IL*1*DROF*T*G***MI*525172765@
3164 DTM*232*20020607@
3165 DTM*233*20020607@
3166 PER*CX*ISSUING SERVICE CENTER*TE*4015551212@
3167 SVC*HC<88141<90*44*22.08@
3168 DTM*472*20020607@
3169 CAS*CO*45*21.92@
3170 SVC*HC<88142<90*53*53@
3171 DTM*472*20020607@
Line Level Balancing
Changes Payments Adjustments Balance
44 svc02 22.08 svc03 21.92 CAS03/06/09/12/15/18 00
53 svc02 53.00 svc03 00. CAS03/06/09/12/15/18 00
Transaction Balancing:
97 clp03 53.00 clp04 22.08 cas @ claim level
21.92 cas @ line level 00
Cross Footing:
97 75.08 44.00 <22.08>
== <> <> <>
In the above example, the transaction does not cross foot. The IG on page 20
states:
When specific service detail is presented, the claim level balancing includes
balancing the total claim charge (CLP03) to the sum of the related service
charges (SVC02). Service lines that are not finalized should be adjusted
with a CAS segment using a Claim Adjustment Group code (CAS01) of 'OA'
(Other Adjustment), a Claim Adjustment Reason code (CAS02) of 133 (This
service is suspended pending further review) and the full dollar amount for
the service in CAS03. When finalized, the claim must be reported using the
instructions found in the Reversal and Correction section. See 2.2.11, Definition
of a Claim, for variations related to claim splitting situations.
It does not address the issue of previous payments and using the 'OA' with a
Claim Adjustment Reason code (CAS02) of 13 to report previous payments and
insuring the transaction cross foots the totals.
I believe the claim should resemble the following:
3160 *CLP*018918525*1*97*53**15*13221979281508@
3161 NM1*QC*1*DROF*TREBOR****MI*525172765@
3162 NM1*IL*1*DROF*T*G***MI*525172765@
3163 DTM*232*20020607@
3164 DTM*233*20020607@
3165 PER*CX*ISSUING SERVICE CENTER*TE*4015551212@
3166 SVC*HC<88141<90*44*0@
3167 DTM*472*20020607@
3168 CAS*OA*B13*22.08@
3169 CAS*CO*45*21.92@
3170 SVC*HC<88142<90*53*53@
3171 DTM*472*20020607@
Line Level Balancing
Changes Payments Adjustments Balance
44 svc02 00.00 svc03 44 CAS03/06/09/12/15/18 00
53 svc02 53.00 svc03 00. 00
Transaction Balancing:
97 clp03 53.00 clp04 44 cas @ line level 00
Cross foot:
97 53.00 44.00 00
== == == ==
Can anyone give me some feed back as to if a claim needs to cross foot?
Bob Ford - ӿ�*
[EMAIL PROTECTED]
401-822-1962
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