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835 Health Care Claim Payment/Advice Procedure Code Bundling:The provider submits procedure code A and B for $100.

00 each to his or her PPOs(Preferred Provider Organization) as primary coverage. The procedures were performed on the same date of service The PPOs adjudication system screens the submitted procedures and notes that procedure C covers the services rendered by the provider on that single date of service. The PPOs maximum allowed amount for procedure C is $120.00. The patients co-insurance amount for procedure C is $20.00. The patient has not met the $50.00 deductible (an agreed amount that must be paid by an insured person making a claim against an insurance policy before an insurer will pay any compensation). Example:-

A=100 B=100

C=200

(Payee amount=charges amount Sum of adjustment amount)

CLP*123456789*1*200*50*70*12~ CLP: Claim Payment Information CLP01: claim submitters identifier CLP02: Processed as Primary (1 INDICATE processed as Primary) CLP03: Monetary Amount (Total Claim Charge Amount) CLP04: Monetary Amount (Claim Payment Amount) CLP05: Monetary Amount (Patient Responsibility Amount) CLP06: Claim Filing Indicator Code (12 INDICATE Preferred Provider Organization (PPO)) CAS*PR*1*50~ CAS: CAS01: Claim Adjustment Group Code (PR IS Patient Responsibility) CAS02: Claim Adjustment Reason Code (Code identifying the entailed reason the adjustment was made) CAS03: Monetary Amount (When the submitted charges are paid in full, the Value for CAS03 should be zero.)

SVC*HC: C*100*100**1*HC: A~ (THIS SEGMENT IS NEW PROCEDURAL CODE) SVC: SVC01: HC (Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes) (TOTAL PAYMENT OF C) SVC02: Monetary Amount (Line Item Charge Amount) SVC03: Monetary Amount (Line Item Provider Payment Amount) SVC04: Product/Service ID SVC05: Quantity (SVC05 is the paid units of service.) SVC06: COMPOSITE MEDICAL PROCEDURE DENTIFIER CAS*OA*94*-100~ CAS: CAS01: Claim Adjustment Group Code (OA- Other adjustments) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE) CAS*CO*45*80~ CAS01: Claim Adjustment Group Code (CO- Contractual Obligations Use this code when a Joint payer/payee contractual agreement or aulatory requirement resulted in an adjustment.) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE)

CAS*PR*2*20~ CAS01: Claim Adjustment Group Code (PR- Patient Responsibility) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE)

SVC*HC: C*100*0**1*HC: B~ SVC: SVC01: HC (Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes) (TOTAL PAYMENT OF C) SVC02: Monetary Amount (Line Item Charge Amount) SVC03: Monetary Amount (Line Item Provider Payment Amount) SVC04: Product/Service ID SVC05: Quantity (SVC05 is the paid units of service.) SVC06: COMPOSITE MEDICAL PROCEDURE DENTIFIER

CAS*CO*97*100~ CAS01: Claim Adjustment Group Code (CO- Contractual Obligations Use this code when a Joint payer/payee contractual agreement or aulatory requirement resulted in an adjustment.) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE)

Procedure Code Unbundling

B=60 A=200 C=60

The same PPO provider submits a claim for one service. The service code is A with a claim submitted charge and service charge of $200.00. The payer unbundles this into 2 services B and C each with an allowed amount of $60.00. There is no deductible or co-insurance amount. Only segments specific to unbundling are included in the example. Adjustment reason code 45, charges exceed your contracted/legislated fee arrangement, is used for each service.

CLP*123456789*1*200*120*0*12~ CLP01: claim submitters identifier CLP02: Processed as Primary (1 INDICATE processed as Primary) CLP03: Monetary Amount (Total Claim Charge Amount) CLP04: Monetary Amount (Claim Payment Amount) CLP05: Monetary Amount (Patient Responsibility Amount) CLP06: Claim Filing Indicator Code (12 INDICATE Preferred Provider Organization (PPO))

SVC*HC:B*200*60**1*HC:A~ SVC01: HC (Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes) (TOTAL PAYMENT OF C) SVC02: Monetary Amount (Line Item Charge Amount) SVC03: Monetary Amount (Line Item Provider Payment Amount) SVC04: Product/Service ID SVC05: Quantity (SVC05 is the paid units of service.) SVC06: COMPOSITE MEDICAL PROCEDURE IDENTIFIER

CAS*CO*45*140~ CAS01: Claim Adjustment Group Code (CO- Contractual Obligations Use this code when a Joint payer/payee contractual agreement or aulatory requirement resulted in an adjustment.) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE) SVC*HC: C*0*60**1*HC:A~ SVC01: HC (Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes) (TOTAL PAYMENT OF C) SVC02: Monetary Amount (Line Item Charge Amount) SVC03: Monetary Amount (Line Item Provider Payment Amount) SVC04: Product/Service ID SVC05: Quantity (SVC05 is the paid units of service.) SVC06: COMPOSITE MEDICAL PROCEDURE IDENTIFIER CAS*CO*94*-60~ CAS01: Claim Adjustment Group Code (CO- Contractual Obligations Use this code when a Joint payer/payee contractual agreement or aulatory requirement resulted in an adjustment.) CAS02: Claim Adjustment Reason Code CAS03: Monetary Amount (Adjustment Amount) (SUM OF CPT CHARGES OTHER THEN FIRST ONE)

837 Health Care Claim Payment/Advice Procedure Code Bundling:The provider submits procedure code A and B for $100.00 each to his or her PPOs (Preferred Provider Organization) as primary coverage. The procedures were performed on the same date of service The PPOs adjudication system screens the submitted procedures and notes that procedure C covers the services rendered by the provider on that single date of service. The PPOs maximum allowed amount for procedure C is $120.00. The patients co-insurance amount for procedure C is $20.00. The patient has not met the $50.00 deductible (an agreed amount that must be paid by an insured person making a claim against an insurance policy before an insurer will pay any compensation). Example:-

A=100 B=100

C=200

(Payee amount=charges amount Sum of adjustment amount) Original 837(primary)

LX*1~ (Loop 2400)


1 = Service line 1

SV1*HC: A*100*UN*1**N~ SV101: HC = HCPCS qualifier SV102: A = HCPCS code SV103:100 = Submitted charge SV104: UN = Units code SV105:1 = Units billed SV106: N = Not an emergency code REF*6R*2J01K~ REF01: 6R = Line item control number code REF02: 2J01K = Control number for this line LX*2~ (Loop 2400) LX 2 = Service line 2 SV1*HC: B*100*UN*1**N~ SV101: HC = HCPCS qualifier SV102: B = HCPCS code SV103:100 = Submitted charge SV104: UN = Units code SV105:1 = Units billed SV106: N = Not an emergency code

REF*6R*2J02K~ REF01:6R = Line item control number REF02:2J02K = Control number for this line
837 Claim Level (Loop ID-2320) (Secondary)

CAS*PR*1*50~ CAS01: PR = Patients Responsibility CAS02: 1 = Adjustment reason - Deductible amount CAS03: 50 = Amount of adjustment
Service Line Level (Loop ID-2400)

SV1*HC: A*100*UN*1**N~ SV101: HC = HCPCS qualifier SV102: A = HCPCS code SV103: 100 = Submitted charge SV104: UN = Units code SV105: 1 = Units billed SV106: N = Not an emergency code REF*6R*2J01K~ REF01:6R = Line item control number REF02: 2J01K = Control number for this line SVD*PAYER ID*70*HC: C**1~ (Loop 2430) SVD01: Payer ID = ID of the payer who adjudicated this service line SVD02:70 = Payer amount paid SVD03: HC = HCPCS qualifier SVD04: C = HCPCS code for bundled procedure SVD05: 1=aid units of service SVD06:2J01K = Line item control number CAS*PR*2*20~ CAS01: Patient Responsibility CAS02:1= Adjustment reason Co-insurance amount CAS03:20= Amount of adjustment LX*2~ (Loop 2400) Lx01:2=service line 2 SV1*HC: B*100*UN*1**N~ SV101: HC = HCPCS qualifier SV102: B = HCPCS code SV103:100 = Submitted charge SV104: UN = Units code SV105:1 = Units billed SV106: N = Not an emergency code REF*6R*2J02K~ REF01:6R = Line item control number code REF02:2J02K = Control number for this line

SVD*PAYER ID*0*HC:C*1*2J01K~ (Loop 2430) SVD01: Payer ID = ID of the payer who adjudicated this service line SVD02:0 = Payer amount paid SVD03: HC = HCPCS qualifier SVD04: C = HCPCS code for bundled procedure SVD05:1 = Units paid SVD06:2J01K = Service line into which this service line was bundled CAS*CO*97*100~ CAS01: CO = Contractual obligations qualifier CAS02: 97 = Adjustment reason - Payment is included in the allowance for the basic
service/procedure CAS03 100 = Amount of adjustment

Procedure Code Unbundling

B=60 A=200 C=60

The same PPO provider submits a claim for one service. The service code is A with a claim submitted charge and service charge of $200.00. The payer unbundled this into 2 services B and C each with an allowed Amount of $60.00. There is no deductible or co-insurance amount. Claim Level (Loop ID-2320) Only segments specific to unbundling are included in the following example.

CAS*OA*93*0~ CAS01: OA = other adjustments qualifier CAS02:93 = Adjustment reason - No claim level adjustments. CAS03:0 = Amount of adjustment
Service Line Level (Loop ID-2400):

LX*1~ LX01:1 = Service line 1 SV1*HC: A*200*UN*1**N~ SV101: HC = HCPCS qualifier SV102: A = HCPCS code SV103:200 = Submitted charge

SV104: UN = Units code SV105:1 = Units billed SV106: N = Not an emergency code REF*6R*JR001426789~ REF01:6R = Line item control number code REF02:JR001426789 = Control number for this service line
Service Line Adjudication Information: (Loop ID-2430)

SVD*PAYER ID*60*HC: B**1~ SVD01: Payer ID = ID of the payer who adjudicated this service line SVD02:60 = Payer amount paid SVD03: HC = HCPCS qualifier SVD04: B = Unbundled HCPCS code CAS*CO*45*35~ CAS01: CO = Contractual obligations qualifier CAS02:45 = Adjustment reason Charges exceed your contracted/legislated fee
arrangement

CAS03:35 = Amount of adjustment SVD*PAYER ID*60*HC: C SVD01: Payer ID = ID of the payer who adjudicated this service line SVD02:60 = Payer amount paid SVD03: HC = HCPCS qualifier SVD04: B = Unbundled HCPCS code CAS*CO*45*45~ CAS01: CO = Contractual obligations qualifier CAS02:45 = Adjustment reason Charges exceed your contracted/legislated fee
arrangement

CAS03:35 = Amount of adjustment