When CLP05 and the sum of PR segments does not match, is the value in CLP05 what the patient responsible for? Or is it the sum of all PR segments? Is it a valid X12 835 if the value in CLP05 does not match the sum of PR segments?
A patient has two coverages. The primary payer sent a payment including patient responsibility amounts. This is sent onto the secondary payer who also pays. In CLP05 the secondary payer reports no value. At the service level they report a PR segment with a value.
Is the patient responsible for the sum of PR segments, or the value reported in CLP05? Or is this an invalid remit and the value in CLP05 should always be the sum of the reported PR segments?
If the value in CLP05 is the patient responsible amount and it is not zero, how would a provider apply it to the service payment information if the PR amounts do not match?
It is challenging to know what the value the patient actually owes when the value in CLP05 and the sum of PR segments do not match. If we receive a payment where PR segments across lines do not add up to the value in CLP05, we don't know how much of the value in CLP05 applies to each service line.
Why is the receiver's bank account# required in the file format if there is no payment being created by this file?
CLP05 must equal the sum of all claim and service line adjustments with Claim Adjustment Group Code PR. The exception is reversals (see section 188.8.131.52 of the 835 5010 TR3 guide). Note, CLP05 is not part of the transaction balancing.
As it relates to the question concerning two coverages, the secondary payer should not re-report prior payer patient responsibility amounts. The secondary payer should report PR adjustments that they have assigned per their adjudication. For example, if the prior payer had reported PR amounts and the secondary payer has paid those amounts, there would not be any CAS segments with PR nor CLP05 amounts to report.