Based on a previous RFI response and the rules in the TR3, is the following "rule" accurate? When SVC03 Line Item Provider Payment Amount is zero, then SVC05 Units of Service Paid Count must be zero If so, would this rule apply universally under the conditions below? Service line zero amount paid based on: Duplicate Non-compensability Deductible Benefit limits exhausted Co-pay If the SVC05 represents the actual paid units does this mean that there is no element to report the adjudicated units? In cases where the line paid amount represents a portion of a whole unit (e.g. deductible, limit exhausted) should a partial paid unit be reported if a whole unit was billed?
For your requested business scenarios this general principle guidance should help you to determine if you need to present adjusted units. SVC05 is the sum of the original submitted provider units that are considered for payment under the benefit provisions of the health plan (covered). This excludes units considered not covered (e.g. duplicate submissions, visits) but includes reductions to payments of covered services (e.g. reductions for amounts over fee schedule and patient deductibles). SVC07 is the original submitted units. When the unit count is not an influencing factor in the adjudication outcome for the line, and the service is either partially or fully covered, the units are generally not adjusted and the original submitted units would be placed in the SVC05 element.