I'd like clarification on the SVC segment, for when they are required to send the segment and loop. The Situational Rule states required when priced at the service line level or when the payment is different than original submitted charges. Can you go into detail on what this functionally means? The first part i'm not sure about, but the second requirement sounds like it's stating if they pay any other amount than 100% of the charge amount. We have a payer that is not sending back any SVC segment when the claim is secondary, and something having to do with the patients deductible. They are paying a positive amount, not 100% of the charge amount. Thank you for your time.
The SVC – Service Payment Information Segment Situational Rule defines when to report the SVC segment at the 2110 loop. This situational rule is intended to convey that the SVC is required in the following 4 situations:
1) all service lines in a professional claim,
(2) all service lines in a dental claim,
(3) all service lines in an outpatient claim priced at the service line level, or
(4) all service lines in a claim whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments.
Per the TR3 Note 1, refer to Section 18.104.22.168.1 Service Line Balancing which also states: Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim.
Also refer to RFI #195