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”
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 | ~ |
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 | ~ |
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 | ~ |
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 | ~ |
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
JSON to EDI 837 Professional
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