Monday, 12 May 2014

EDI 5010 Documentation 837 Professional - Loop 2430 Line Adjudication Information


        

This loop is required only if current insurance sequence > 1. i.e. for secondary, tertiary, etc.

Say for example, if the current insurance is secondary, then we should run this loop for the primary insurance. If the current insurance is tertiary, then we should run this loop for the primary and then secondary insurance. And also so on. In general, take the sequence number of the current insurance, and run this loop for all the previous sequence insurance.

We need to repeat this loop for each line item in the claim.

When submitting coordination of benefits (COB) claims to Secondary Payer, the prior payer’s payment information must be included in the 837 claim file. There is important edit takes places in COB Claims at line item level for balancing the amounts.This edit is to verify that each charge line balances with the payment information at the line level. An example of line level balancing is below. The data in red provides an example of how the line level must balance.
 
Service Level (Loop 2400) line item charge amount Professional (SV102) or line item charge amount Institutional (SV203) = the sum of all other payer service line paid amounts (SVD02) at the service level (Loop 2430) + the sum of all the service line adjustments (CAS03) at the service level (Loop 2430)
 
Line level balancing:
SV1*HC:90834*137*UN*1***1:2:3
DTP*472*D8*20130513
SVD*99726*47.28*HC:90834**1
CAS*CO*45*77.86
CAS*PR*2*11.86
137 = 47.28 + 77.86 + 11.86

 

If there is balancing issue, then you will receive “Secondary Claim Information Missing or Invalid - Each line must balance; Line Charge Amount = Line Sum Of Adjustment Amounts + Line Payer Paid Amount”


2430 Line Adjudication Info - SVD Segment

Loop Seg ID Segment Name Format Length Ref# Req Value
2430 SVD Line Adjudication Information ID 3 S SVD
Element Separator AN 1 *
SVD01 Identification Code ID 1/2 1033 R PR
Element Separator AN 1 *
SVD02 Monetary Amount ID 1/5 1034 R 1
Element Separator
SVD03-1 Product/Service ID Qualifier ID 2 235 R HC
Component Element Separator 1 :
SVD03-2 Product/Service ID 2 Procedure Code
Component Element Separator 1 :
SVD03-3 Procedure Modifier AN 2 1339 Modifier1
Component Element Separator 1 :
SVD03-4 Procedure Modifier AN 2 1339 Modifier2
Component Element Separator 1 :
SVD03-5 Procedure Modifier AN 2 1339 Modifier3
Component Element Separator 1 :
SVD03-6 Procedure Modifier AN 2 1339 Modifier4
Component Element Separator 1 :
SVD03-7 Description Not Used  
Element Separator *
SVD04 Description Not Used
Element Separator *
SVD05 Quantity R Line Item Unit
Segment Terminator  

2430 Line Adjustment CAS - Deductible

Loop Seg ID Segment Name Format Length Ref# Req Value
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment Group Code ID 1/2 1033 R PR
Element Separator AN 1 *
CASE02 Claim Adjustment Reason Code ID 1/5 1034 R 1
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Print the Deductible Amount
Segment Terminator ~
 
2430 Line Adjustment CAS – Coinsurance
Loop Seg ID Segment Name Format Length Ref# Req Value
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment Group Code ID 1/2 1033 R PR
Element Separator AN 1 *
CASE02 Claim Adjustment Reason Code ID 1/5 1034 R 2
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Print the Coinsurance Amount
Segment Terminator ~
 
2430 Line Adjustment CAS – Co-pay
Loop Seg ID Segment Name Format Length Ref# Req Value
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment Group Code ID 1/2 1033 R PR
Element Separator AN 1 *
CASE02 Claim Adjustment Reason Code ID 1/5 1034 R 3
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Print the Co-pay Amount
Segment Terminator ~

2430 Line Adjustment CAS – Insurance Adjustments
Loop Seg ID Segment Name Format Length Ref# Req Value
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment Group Code ID 1/2 1033 R CO
Element Separator AN 1 *
CASE02 Claim Adjustment Reason Code ID 1/5 1034 R 45
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Print the Insurance Adjustments
Segment Terminator ~
 

 
2430 Line Adjustment DTP Line Adjudication Date

Loop Seg ID Segment Name Format Length Ref# Req Value
2430 DTP Line Adjudication Date ID 3 R DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 573
Element Separator AN 1 *
DTP02 Date time Period Format Qualifier ID 2/3 1250 R D8
Element Separator AN 1 *
DTP03 Date time Period ID 1/35 1251 R CCYYMMDD
Segment Terminator ~

Example

SBR*P*18*******CI
AMT*D*52.01
OI***Y***Y
NM1*IL*1*Dianna*Jody****MI*XY31232
N3*4 B Blue Ridge Blvd
N4*Hamilton*OH*45011
NM1*PR*2*FLORIDA BLUE*****PI*BCBSF
LX*1
SV1*HC:99213*195.00*UN*1.00*11**1
DTP*472*RD8*20140905-20140905
REF*6R*219
SVD*BCBSF*52.01*HC:99213**1.00
CAS*PR*2*13.00
CAS*CO*45*129.99
DTP*573*D8*20140905

 

For complete Example, please refer to use case 9,10,12 in the Home page

 

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Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com. 

1 comment:

  1. If you have the examples for bundling and unbundling in EDI837 Secondary file?

    ReplyDelete