--------Original Message-----
From: McDaniel, Laurie [mailto:[EMAIL PROTECTED]
Sent: Thursday, March 27, 2003 2:23 PM
To: WEDI SNIP Transactions Workgroup List
Subject: RE: 4010 837I compliance issueBut obviously fictitious data.--------Original Message-----
From: Doug Fielding [mailto:[EMAIL PROTECTED]
Sent: Thursday, March 27, 2003 2:19 PM
To: WEDI SNIP Transactions Workgroup List
Subject: RE: 4010 837I compliance issueNice broadcasting of PHI--------Original Message-----
From: Bill [mailto:[EMAIL PROTECTED]
Sent: Thursday, March 27, 2003 12:48 PM
To: WEDI SNIP Transactions Workgroup List
Subject: 4010 837I compliance issueHi,
Here is a breakdown of what I found with a compliance failure with the 4010 837I
The error is (CLM/02 != SUM(SV2/03)) . This is in LX*5 in bold below
the 37th iteration of loop 2000B (Subscriber HL). CLM02=5488.02 and the
amounts of SV203 total 7927.02. This is a difference of 2439.00, which
is the exact amount of this SV2:
SV2*0300*HC:88180:91*2439*UN*3**2439~
SV2-01=0300 Revenue Code
SV2-02-01=HC Healthcare (service)
SV2-02-02=88180 Service ID/Product ID
SV2-02-03=91 Procedure Modifier
SV2-03=2439 Monetary Amount
SV2-04=UN Unit
SV2-05=3 Quantity
SV2-06=<empty> Unit Rate
SV2-07=2439 Monetary Amount
The key here is that SV2-07 is "Line Item Denied Charge or Non-Covered
Charge Amount" which nullifies the amount in SV2-03. There is nothing
in the IG that states that denied charges should be subtracted from
CLM02 or that SV2-03 amounts should subtract SV2-07 from SV2-03 prior to
adding them for CLM reconciliation. This would appear to make sense
logically but there are no business cases or documentation within HIPAA to
support this theory.
Can anyone supply me with an Industry Wide business case to prove
otherwise? If not I then can't escalate this compliance failure to development
because the software vendor feels that the map is functioning within HIPAA
guidelines.
here is the whole claim
thanks
Bill Swaney
HIPAA Consultant
CLM*5006902851*5488.02***13:A:1*Y**Y*Y*********Y~
DTP*096*TM*0000~
DTP*434*RD8*20021007-20021007~
DTP*435*DT*200210070600~
CL1*3*1*01~
REF*EA*315470~
HI*BK:2893*BJ:2893~
HI*BF:2141*BF:V1079~
HI*BR:4023:D8:20021007~
HI*BQ:863:D8:20021007~
HI*BE:17:::27.02*BE:A2:::498.63~
NM1*71*1*GRABLE*B****24*123456789~
PRV*AT*ZZ*203B00000N~
REF*1G*E60251~
NM1*72*1*GRABLE*B****24*123456789~
PRV*OP*ZZ*203BS0100Y~
REF*1G*E60251~
NM1*73*1*GRABLE*B****24*123456789~
PRV*PE*ZZ*203B00000N~
REF*1G*E60251~
SBR*P*18**MEDICARE A*****MA~
CAS*CO*70*27.02**A2*1794.73~
CAS*OA*96*2439~
CAS*PR*2*498.63~
AMT*C4*755.66~
AMT*B6*5488.02~
AMT*T3*7927.02~
AMT*N1*755.66~
AMT*B1*755.66~
AMT*A8*2439~
AMT*YT*2439~
DMG*D8*19401211*F~
OI***Y***Y~
NM1*IL*1*GEDDY*ESTELLE*L***MI*010327595A~
N3*54 OAK AVE APT~
N4*FITCHBURG*MA*014203138~
NM1*PR*2*ASS HOSP SVC 81*****PI*00181~
N3*2 GANNETT DRIVE~
N4*SOUTH PORTLAND*ME*041066911~
DTP*573*D8*20021106~
REF*F8*1229630223~
NM1*71*1~
REF*1G*E60251~
NM1*72*1~
REF*1G*E60251~
LX*1~
SV2*0250*HC:LMNOP*4.02*UN*3~
DTP*472*D8*20021007~
SVD*00181*0**0250*3~
DTP*573*D8*20021106~
LX*2~
SV2*0258*HC:LMNOP*17*UN*1~
DTP*472*D8*20021007~
SVD*00181*0**0258*1~
DTP*573*D8*20021106~
LX*3~
SV2*0270*HC:LMNOP*297*UN*1~
DTP*472*D8*20021007~
SVD*00181*0**0270*1~
DTP*573*D8*20021106~
LX*4~
SV2*0271*HC:LMNOP*45*UN*1~
DTP*472*D8*20021007~
SVD*00181*0**0271*1~
DTP*573*D8*20021106~
LX*5~
SV2*0300*HC:88180:91*2439*UN*3**2439~
DTP*472*D8*20021007~
SVD*00181*0*HC:88180:91*0300*3~
CAS*OA*96*2439~
DTP*573*D8*20021106~
LX*6~
SV2*0310*HC:88304*201*UN*3~
DTP*472*D8*20021007~
SVD*00181*29.78*HC:88304*0310*3~
CAS*PR*2*34.97~
DTP*573*D8*20021106~
LX*7~
SV2*0360*HC:11402*598*UN*1~
DTP*472*D8*20021007~
SVD*00181*74.43*HC:11402*0360*1~
CAS*PR*2*42.9~
DTP*573*D8*20021106~
LX*8~
SV2*0360*HC:11402*598*UN*1~
DTP*472*D8*20021007~
SVD*00181*74.43*HC:11402*0360*1~
CAS*PR*2*42.9~
DTP*573*D8*20021106~
LX*9~
SV2*0360*HC:12032*598*UN*1~
DTP*472*D8*20021007~
SVD*00181*40.55*HC:12032*0360*1~
CAS*PR*2*22.82~
DTP*573*D8*20021106~
LX*10~
SV2*0360*HC:38525*1196*UN*1~
DTP*472*D8*20021007~
SVD*00181*509.45*HC:38525*0360*1~
CAS*PR*2*355.04~
DTP*573*D8*20021106~
LX*11~
SV2*0370*HC:LMNOP*559*UN*1~
DTP*472*D8*20021007~
SVD*00181*0**0370*1~
DTP*573*D8*20021106~
LX*12~
SV2*0710*HC:LMNOP*1375*UN*1~
DTP*472*D8*20021007~
SVD*00181*0**0710*1~
DTP*573*D8*20021106~
HL*56*53*22*0~
SBR*S*18*M02111001******ZZ~
NM1*IL*1*BAEZ*JOAN****MI*011247822A~
N3*406 ELM ST~
N4*FITCHBURG*MA*014206726~
DMG*D8*19310716*F~
NM1*PR*2*MEDICAID*****PI*M02111001~
N3*600 WASHINGTON ST.~
N4*BOSTON*MA*02111~
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