A payer rejected an 837P claim with the following rejection:
* COB PAYER PAID + ADJUSTMENT AMOUNTS = 327.19 NOT EQUAL TO CLM02 - 177.7 * LINE: 88 LOOP: 2430 TOTAL CLAIM CHARGE AMOUNT
For the rejected claim, the figures in the rejection message reflect the sum of the service line payments of 177.70 being added to the total of the claim level adjustment amounts of 149.49 to arrive at 327.19 not equaling the total charge amount of 177.7. The claim payment amount of 28.21 was not used in the formula.
As shown in the 837P transaction information below, the rejected claim was improperly submitted with each service line showing a payment in full and adjustments at the claim level. This scenario allowed the claim to balance according to sections 1.4.4, 1.4.4.1, and 1.4.4.2 in the 837P guidelines. However, as indicated in the rejection message, the claim does not balance to the total charge.
2300
CLM*ABC123*177.7***22>B>1*Y*A*Y*Y~
2320
CAS*CO*45*123.13~
CAS*OA*20*23.36~
CAS*PR*2*3~
AMT*D*28.21~
2400
LX*1~
SV1*HC>12345*43.3*UN*1***1~
2430
SVD*12345*43.3*HC>12345**1~
AMT*EAF*0~
2400 LX*2~
SV1*HC>12345*21.7*UN*1***1~
2430
SVD*12345*21.7*HC>12345**1~
AMT*EAF*0~
2400
LX*3~
SV1*HC>12345*100.8*UN*1***1~
2430
SVD*12345*100.8*HC>12345**1~
AMT*EAF*0~
2400
LX*4~
SV1*HC>12345*11.9*UN*1***1~
2430
SVD*12345*11.9*HC>12345**1~
AMT*EAF*0~
To prevent future rejections, we would like to put an edit in our system but need confirmation as to whether it is appropriate to always perform the balancing formula as performed by the payer. Is there a reason why this formula is not mentioned in the 837P guidelines? Would it be appropriate to also perform this calculation on 837I claims that include service line payment information?
There is no requirement that the billed amount (2300 CLM02) equal the sum of the line level payer paid amount (2430 SVD02) plus the header level payer adjustment amounts (2320 CAS).
The guides for institutional claims (005010X223A2) and professional claims (005010X222A1) as indicated in section 1.4 require that the payer paid amount (2320 AMT02) equal the sum of the line level payments (2430 SVD02) minus the header level adjustment amounts (2320 CAS). The guides also require that the total claim change amounts (2300 CLM02) equal the sum of the service line charge amounts (2400 SV102). Adjustment amounts within the CAS segment decrease the payment amount when the adjustment amount is positive, and increase the payment amount when the adjustment amount is negative. In the example provided the claim is balanced according to these rules.
There is nothing improper in reporting adjustments at the claim level. The guides allows for such reporting to accommodate instances where the payer did not report line level adjustments to the provider.