Mike,
Here is
what I find in the 835: Notice 2.2.1.1 Service Line
Balancing (capitalization is theirs, not mine)
2.2.1 Balancing
The amounts reported in the 835, if
present, MUST balance at three
different levels
- the service line, the claim, and the
transaction. Adjustments within the 835,
through use of the Claim Adjustment and
Service Adjustment Segments, CAS, or
Provider Adjustment Segments, PLB,
DECREASE the payment when the
adjustment
amount is POSITIVE, and INCREASE the payment when the
adjustment
amount is NEGATIVE. See 2.2.4, Claim Adjustment and
Service Adjustment Segment
Theory, for more
details.
2.2.1.1 Service Line
Balancing
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.
When used, the submitted service
charge minus the sum of all monetary
adjustments must equal the amount paid
for this service line.
Table 2 - Detail
POS. # SEG. ID NAME USAGE REPEAT LOOP
REPEAT
David G. Foulke
Software Development
Dairyland Healthcare
Solutions
320-634-5331
[EMAIL PROTECTED]
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-----Original
Message-----
From: Mike Urban
[mailto:[EMAIL PROTECTED]
Sent: Monday, September 22, 2003 9:23
AM
To: Dave Foulke; WEDI SNIP
Transactions Workgroup List
Subject: RE: COB
Balancing
No. This note in the SVC is pretty
clear:
Although the SVC loop
is optional, there are times when it should be considered mandatory. Whenever
the actual payment has been reduced due to service line specific adjustments,
the SVC loop is necessary in order to understand the remittance information.
This situation is particularly applicable to professional and fee-based
services.
Even if you consider "should be
considered mandatory" to by synonymous with "required" (they are not),
the SVC segment is only needed when adjustments reduce the amount
paid.
-----Original
Message-----
From: Dave
Foulke [mailto:[EMAIL PROTECTED]
Sent: Monday, September 22, 2003 8:54
AM
To: WEDI SNIP
Transactions Workgroup List
Subject: RE: COB
Balancing
Correct me if I'm
incorrect, but 835's returning payment information on professional claims
are required to return service line information are they not?
Therefore there has to be SOME service line information, even it's nothing
more than one payment.
Thanks
Dave
David G.
Foulke
Software
Development
Dairyland
Healthcare Solutions
320-634-5331
[EMAIL PROTECTED]
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information is confidential and is for the use of the intended recipient
only. Any improper use of this information is strictly prohibited. If you
have received this e-mail in error, please reply to the sender immediately
and delete this communication
-----Original
Message-----
From: Doug
Webb [mailto:[EMAIL PROTECTED]
Sent: Monday, September 22, 2003 8:16
AM
To: WEDI SNIP
Transactions Workgroup List
Cc: WEDI SNIP Transactions Workgroup
List
Subject: Re: COB
Balancing
Also, how can the Clearinghouse
possibly know what the EOB or 835 you received
contained?
As you pointed out, the 837 must
accurately report what was received from the primary
payer.
Requiring service-line level
adjustments when you do not have service-line level information is just
plain wrong.
The opinions expressed here are
my own and not necessarily the opinion of LCMH.
Douglas M. Webb
Computer
System Engineer
Little Company of Mary Hospital & Health Care
Centers
[EMAIL PROTECTED]
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----- Original Message -----
Sent:
Monday, September 22, 2003 07:16 AM
Subject: Re:
COB Balancing
Jenn, what is reported on the
remittance advice is what must be reflected
on the 837
secondary/tertiary claim(s). The 835 Implementation Guide on
page
20 near the bottom in the description for Amount 8 the note
indicates
the amount can be transmitted in the Claim Adjustment Segment
and/or the
Service Adjustment Segment. Additionally, the third
paragraph on page 21
states "When the Service Payment Information loop
is present, adjustments
are reported in either (emphasis added) the
Claim Adjustment or the Service
Adjustment Segments but not in
both. The example provided basically points
out that the same
adjustment should not be repeated at both the claim and
service
level. Also the IG notes the preference that the adjustment
be
shown at the service level when possible.
I do not see how a
clearinghouse can demand that adjustments be shown at
the service level
if the prior payer reported the adjustments at the claim
level.
At the same time you might as well be prepared to report service
level
adjustments when a payer adjudicates and returns service
level
adjustments.
Robert C. Pozniak
NYS Department of
Health
HIPAA Practice
Group
"Jones,
Jennifer"
<[EMAIL PROTECTED]
To: "WEDI SNIP Transactions Workgroup
List"
ech.com>
<[EMAIL PROTECTED]>
cc:
09/19/2003 03:55
Subject: COB
Balancing
PM
Please respond
to
"Jones,
Jennifer"
I'm sure it is late in the game to asking
about this but I haven't had this
request until recently ?
I
have aClearinghouse who is requesting COB information at both the
claim
and line level.I have not been doing this for other payers so now
I'm
forced to change it (for one situation).
I'm frustrated
because I've gotten this far in the game and been able to
successfully
send COB claims with this information at only the claim
level.
Iguess, before I do it, I want to make sure I should
?
Thanks --- jenn
____________________
Jennifer Lynne
Jones
Sanitas Product Manager>
Pinpoint
Technologies
Boulder, CO 80301
303-801-1829
(Direct)
303-801-0001 (Fax)
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