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 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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