Please clarify the 5010 TR3 Front Matter section 1.4.4.2, Service Line Balancing. The 2nd paragraph, 1st sentence, says line level balancing occurs independently for each individual Line Adjudication Information Loop. The 2nd sentence says in order to balance, the sum of the line level adjustment amounts and line level payments in each Line Adjudication Information loop must balance to the provider's charge for that line. There seems to be different interpretations for line level balancing.
If there are 2 SVD loops for payer A, shouldn't all the adjustments and payments for both SVD's balance to the line item charge?
If there are 2 SVD loops, 1 for payer A and 1 for payer B, shouldn't all the adjustments and payments for Payer A and Payer B balance to the line item charge?
The answer to both questions is yes, as described below:
1) If there are 2 SVD (2430) loops for payer A, the combination of adjustments and payments on both SVD (2430) loops must balance to the line item charge.
2) If there are 2 SVD (2430) loops, one for payer A and one for payer B, the sum of the adjustments and payments in the Payer A SVD (2430) loop must balance to the line item charge. Likewise, the sum of the adjustments and payments in the Payer B SVD (2430) loop must also balance to the line item charge.
Section 1.4.4.2 does not address balancing for a service line where the services have been unbundled or split into two or more services for processing by the previous payer. Unbundled services will be added to the Service Line Balancing section in the next version of the guide. Section 1.4.1.4 does provide an example of 2430 SVD and CAS segments on a secondary claim for an unbundled situation.
Unbundled and split services will have two or more 2430 loops within one service line loop, all linked to the same payer by the SVD01. For each service line, the sum of the SVD02 payment amounts plus the CAS adjustment amounts in all 2430 loops for a single payer must add up to the charge in the SV102 for that service line. 2430 loops showing adjudication results of multiple previous payers must balance separately for each payer. Processing results from two separate benefit programs within the same payer are treated as separate payers for purposes of service line balancing and building the segments in the 2430 loops.