In the 835 guide (Section 1.10.2.13), it states that the "impact" of the primary (prior) payer's adjudication should be reported in a CAS segment with OA 23. The "impact" is described as "up to the actual amount of the primary payment(s) plus contractual adjustment(s)." The prior payer contractual adjustments are reported in CAS segments in the 837, but where exactly are the prior payer paid amounts supposed to be sourced from on the 837? From what I can tell, the AMT*D is the sum of the prior payer paid on the claim level. The SVD02 is the prior payer paid amount on the service line, but I am confused about which one should be used and when. If the SVD02 is present on the service lines, but the AMT*D is present on the claim level, are we required to use the service level data when creating the 835? Is it a best practice? Is the choice of SVD vs AMT*D optional?
RFIs #2570 and #2535 touch on the subject but do not specify the data sources. RFI #2023 addresses the source of the data in the 837 but only for the prior payer contractual adjustments and not the prior payer paid amounts.
I understand that the "impact" can be less than the actual prior payer paid + contractual adjustments under certain circumstances, but for the purposes of this RFI, I'm only trying to determine the source of the data, so let’s assume this is a claim where the actual prior payer paid + contractual adjustments equal the "impact" when the secondary payer adjudicates the claim. Also, referring specifically to non-institutional claims with service line detail.
The COB values are reported in the 837 in the Other Payer Loops 2320, 2330A, 2330B, and 2430. If the prior payer’s adjudication was at the claim level, then the amount listed in the CAS with group code OA and CARC 23 is determined by each payer's payment methodology and their assessment of the prior payer's impact (such as the payment from the previous payer). There is no specific guideline for choosing between the 837 SVD and 837 AMT payment amounts when reporting in the CAS OA 23 in the 835. Payers should indicate what prior payer payment amount impacted their payment for the specific line. As a note, the “impact” would also include prior payer adjustments as applicable.