Ensuring that 837 EDI transactions meet validity checks is critical to improving auto-adjudication and encounter submission acceptance rates. SNIP Type 3 describes the rules for balancing header and detail levels of the Claim, Premium Payment and Remittance Advice transaction sets. Previously, our blog covered the logic required to balance 835 transactions. Now we’ll look at the steps necessary to balance claims with service lines, including Coordination of Benefits loops in multiple payer scenarios.
Claims and encounters may be represented by a variety of X12 transaction types: 837 Professional, Institutional and Dental, as well as their corresponding post-adjudicated variants (298, 299, 300), intended for submission to All-Payer Claims Databases. The following logic applies to all versions of the 837 equally, with a few caveats noted below.
Rule 1 – Balancing Claim Charge Amounts
The first claim balancing rule is straightforward: given the parent-child relationship of 2300 claim loops to their 2400 service lines, claim amounts stored in 2300-CLM02 must equal to the sum of their corresponding 2400-SV102 children. Here is a tree view representation of this rule in X12 Studio Toolbox:
For a Professional claim, this could be represented as:
2300-CLM02 = SUM(of each 2400-SV102)
The same rule applies to other claim types, with the caveats that:
- For Institutional claims, SV203 elements should sum to CLM02
- For Dental claims, SV302 elements should sum to CLM02
Rule 2 – Balancing Payments to Claim Lines
The second rule requires a bit more background. 837 transactions may represent a Coordination of Benefits relationship between multiple payers. This scenario occurs when an individual has coverage from two or more plans, and the plans work together to pay a claim. Examples of this are employer coverage plus Medicare, a child covered by two subscribers, or subrogation involving partial payments by workers’ compensation.
This workflow can be handled in at least two ways. In the first model, the provider or clearinghouse transmits the claim to the primary payer, who performs adjudication and responds with an 835 Remittance Advice representing that plan’s responsibility. Next, the provider goes down the chain of auxiliary payers. In each case, the 2000B Subscriber loop is reflected into a 2320 Other Subscriber Information loop. In addition to capturing Subscriber Information, the 2320 Loop includes AMT segments to capture the previous payments, and CAS segments tracking claim adjustment amounts.
The second workflow differs in that payers are responsible for routing 837 claims to subsequent responsible parties. In each case, the auxiliary payer will respond to the provider with an 835 Remittance Advice, and will move prior subscriber and payment information into a new 2320 loop.
In both workflows, adjudicated services moves to the 2430 loop, which contains line level payment amounts and adjustments. This is the point at which balancing comes back into play. For the second SNIP 3 claim balancing rule, each 2320 payer amount must equal the sum of service line payment amounts from the corresponding payer, less any claim level adjustments.
The important nuance here is that the 2320 and 2430 loops can both repeat, and the must be correlated correctly by payer identifier. This is done by linking the 2330B-NM109 element to the corresponding 2430-SVD01 element. Also important to note is that two AMT segments may exist on the 2320 loop. The segment used for claim balancing is AMT*D (Payer Paid Amount). This rule can be represented as:
2320-AMT*D-02 = SUM(of each 2430-SVD02) – (each 2320 claim adjustment: CAS03 + CAS06 + CAS09 + CAS12 + CAS15 + CAS18)
=> WHERE 2330B-NM109 = 2430-SVD01
Rule 3 – Balancing Payments to Service Lines
The final claim balancing rule requires that 2430 Other Payer Line Adjudication Amounts, minus claim adjustments, sum to the line charge amount. The same consideration mentioned for Rule 1 applies to identifying the service line charge amount:
- 837P / 298 PACDR uses SV102
- 837I / 299 PACDR uses SV203
- 837D / 300 PACDR use SV302
This rule can be represented as:
2400 Service Line Charge Amount = SUM(of each 2430-SVD02) – (each 2430 claim adjustment: CAS03 + CAS06 + CAS09 + CAS12 + CAS15 + CAS18)
Unlike structural and HIPAA validations that fall into SNIP Types 1 & 2, claim balancing errors don’t have a predefined place in 999 Acknowledgements. The 277-CA includes status codes which can be used to indicate balancing failures:
This code would be reflected in an STC01 component, with an STC01-01 E code indicating an error, and STC01-02 containing the 400 Claim Status Code. These code sets correspond to the 507 and 508 external lists published by X12.
The T-Connect EDI Management Suite implements SNIP 3 and other predefined and customizable rules to assist health plans and informatics companies manage their validation requirements. T-Connect clients use our software to configure intake, validation and acknowledgement workflows for a range of scenarios. Reach out to us for a free demo or consultation – we’re always happy to talk EDI.