We are producing incorrect 835’s for claims where we bundled services and are in the process of making system changes to correct.

In the following example, the provider submitted six lines of service.  We bundled two lines of service and added a line of service.  This caused an incorrect Total Billed Amount to populate on the 835, extra SVC, DTM, CAS and REF segments and incorrect CAS and SVC segment reporting.

Originally Submitted Claim EDI Data

CLM*25563391*636***11:B:1*Y*C*Y*Y~

LX*1~

SV3*AD:D0150*125****1~

REF*6R*103335053~

LX*2~

SV3*AD:D0274*86****1~

REF*6R*103335054~

LX*3~

SV3*AD:D0330*148****1~

REF*6R*103335055~

LX*4~

SV3*AD:D0603*102****1~

REF*6R*103335056~

LX*5~

SV3*AD:D1110*120****1~

REF*6R*103335057~

LX*6~

SV3*AD:D1206*55****1~

REF*6R*103335058~

 

Six lines of service submitted total claim charge amount was 636.  Two lines of service were denied (D0274 and D0330) and a new line of service was added (D0210) to replace/bundle the denied services.   The added service line had a billed amount of 234 and allowed amount of 70.64.  Manually adding a service line in this bundling process created issues with the resulting 835 and balancing/reconciliation issues for the provider.

•  Not following HIPAA 835 TR3 rules related to bundling claims.

•  Not following HIPAA TR3 rules related to total charge amount (should be total charge amount submitted by provider, but since a new charge was added, it appears the system is adding that charge in the calculation).  The CLP03 should contain the amount submitted by the provider in CLM02.

•  Not following the HIPAA 835 TR3 rules related to the REF*6R segment.  This should be a value submitted by the provider, and if not sent should not be on the 835.

 

Below is data from the 835:

CLP*25563391*1*870*175.54**MC*1164576379805~  CLP03 should be 636.

AMT*AU*175.54~

SVC*AD:D0150*125*35.32~

DTM*472*20220215~

CAS*CO*45*89.68~

REF*6R*103335053~

AMT*B6*35.32~

SVC*AD:D0274*86*0~ This should be SVC*AD:D0210**86*70.64***AD:D0274~

DTM*472*20220215~

CAS*CO*169*86~  Should be CAS*OA*94*-148~ AND CAS*CO*45*163.36~

REF*6R*103335054~

SVC*AD:D0330*148*0~  Should be SVC*AD: D0210 *148*0***AD: D0330~

DTM*472*20220215~

CAS*CO*169*148~  Should be CAS*CO*97*148~

REF*6R*103335055~

SVC*AD:D0603*102*0~

DTM*472*20220215~

CAS*CO*45*102~

REF*6R*103335056~

SVC*AD:D1110*120*54.88~

DTM*472*20220215~

CAS*CO*45*65.12~

REF*6R*103335057~

AMT*B6*54.88~

SVC*AD:D1206*55*14.7~

DTM*472*20220215~

CAS*CO*45*40.3~

REF*6R*103335058~

AMT*B6*14.7~

SVC*AD:D0210*234*70.64~ 

These SVC,DTM, CAS, REF and AMT segments should not be created/sent.

DTM*472*20220215~

CAS*CO*45*163.36~

REF*6R*298137625~

This REF6R should not be sent.  It was not submitted by the provider.

AMT*B6*70.64~