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?
CLP05 must equal the sum of all claim and service line adjustments with Claim Adjustment Group Code PR. The exception is reversals (see section 220.127.116.11 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.
Please refer to RFI# 2143 for additional information related to Secondary Claim Reporting - COB