Dave, it's true that service line specific adjustments must be reported at
the service line detail, such as service not covered or charges exceed our
fee schedule or maximum allowable amount, other adjustments may not be
considered line specific adjustments such as deductibles. Although the
4050 strengthens the wording regarding claim versus line level CAS and
recommends reporting at either or but not both the ability to do so does
exist and therefore providers need to prepare for that possiblity.
Robert C. Pozniak
NYS Department of Health
HIPAA Practice Group
Dave Foulke
<[EMAIL PROTECTED] To: "WEDI SNIP Transactions
Workgroup List"
et.com> <[EMAIL PROTECTED]>
cc:
09/22/2003 11:18 Subject: RE: COB Balancing
AM
Please respond to
Dave Foulke
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
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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
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-----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
Robert,
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
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----- Original Message -----
From:Robert C. Pozniak
To:WEDI SNIP Transactions Workgroup List
Cc:WEDI SNIP Transactions Workgroup List
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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