For certain types of 837i claims, a payer that is always 2ndary to Medicare is reporting the Ded or coins rate in CLP03 of the 835 rather than the total charge amt from the org clm. Page 125 in ANSI5010 835 IG for Loop 2100 CLP segt, the documentation indicates CLP03 is used for monetary amount of Total Clm Chrg Amt.
We provided detail from TR3 to the payer noting that the use of this element. The payer is reporting the same monetary amount in CLP03 as reported in CLP04 for the Clm Pay Amt. This causes issues for our client as they cannot post back the electronic file as CLP03 does not match the total charges sent on the claim. After conveying this to the payer, they have advised that they continue to report back the Ded or daily coins rate in CLP03 and do not plan to modify their system to populate the total charge of the claim in that element.’
Per our interpretation of the TR3 requirements this payer is noncompliant
ASC X12 5010 835 IG X221 addresses this in CLP03 stating in an element note 'Use this monetary amount for the submitted charges for this claim'. Additionally Section 3.3 business scenario for COB reporting indicates CLP03 as the claim's submitted charge, not a deductible or co-insurance amount. Section 1.10.2. states the business situations presented in the guide are the only ones that are compliant with the guide and that creation of 835 transactions that are not consistent with the information in the 835 are prohibited.
Your interpretation is correct, the healthplan's implementation is not consistent with the guide.