EDI 5010 Documentation 837 Professional - Loop 2430 Line Adjudication Information

        

This loop is required only if current insurance sequence > 1. i.e. for secondary, tertiary, etc.

Say for example, if the current insurance is secondary, then we should run this loop for the primary insurance. If the current insurance is tertiary, then we should run this loop for the primary and then secondary insurance. And also so on. In general, take the sequence number of the current insurance, and run this loop for all the previous sequence insurance.

We need to repeat this loop for each line item in the claim.

When submitting coordination of benefits (COB) claims to Secondary Payer, the prior payer’s payment information must be included in the 837 claim file. There is important edit takes places in COB Claims at line item level for balancing the amounts.This edit is to verify that each charge line balances with the payment information at the line level. An example of line level balancing is below. The data in red provides an example of how the line level must balance.
 
Service Level (Loop 2400) line item charge amount Professional (SV102) or line item charge amount Institutional (SV203) = the sum of all other payer service line paid amounts (SVD02) at the service level (Loop 2430) + the sum of all the service line adjustments (CAS03) at the service level (Loop 2430)
 
Line level balancing:
SV1*HC:90834*137*UN*1***1:2:3
DTP*472*D8*20130513
SVD*99726*47.28*HC:90834**1
CAS*CO*45*77.86
CAS*PR*2*11.86
137 = 47.28 + 77.86 + 11.86

 

If there is balancing issue, then you will receive “Secondary Claim Information Missing or Invalid - Each line must balance; Line Charge Amount = Line Sum Of Adjustment Amounts + Line Payer Paid Amount”

2430 Line Adjudication Info - SVD Segment

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	SVD	Line Adjudication Information	ID	3		S	SVD
		Element Separator	AN	1			*
	SVD01	Identification Code	ID	1/2	1033	R	PR
		Element Separator	AN	1			*
	SVD02	Monetary Amount	ID	1/5	1034	R	1
		Element Separator
	SVD03-1	Product/Service ID Qualifier	ID	2	235	R	HC
		Component Element Separator		1			:
	SVD03-2	Product/Service ID		2			Procedure Code
		Component Element Separator		1			:
	SVD03-3	Procedure Modifier	AN	2	1339		Modifier1
		Component Element Separator		1			:
	SVD03-4	Procedure Modifier	AN	2	1339		Modifier2
		Component Element Separator		1			:
	SVD03-5	Procedure Modifier	AN	2	1339		Modifier3
		Component Element Separator		1			:
	SVD03-6	Procedure Modifier	AN	2	1339		Modifier4
		Component Element Separator		1			:
	SVD03-7	Description				Not Used
		Element Separator					*
	SVD04	Description				Not Used
		Element Separator					*
	SVD05	Quantity				R	Line Item Unit
		Segment Terminator

2430 Line Adjustment CAS - Deductible

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	CAS	Line Adjustment	ID	3		S	CAS
		Element Separator	AN	1			*
	CAS01	Claim Adjustment Group Code	ID	1/2	1033	R	PR
		Element Separator	AN	1			*
	CASE02	Claim Adjustment Reason Code	ID	1/5	1034	R	1
		Element Separator	AN	1			*
	CAS03	Monetary Amount	R	1/18	782	R	Print the Deductible Amount
		Segment Terminator					~

 

2430 Line Adjustment CAS – Coinsurance

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	CAS	Line Adjustment	ID	3		S	CAS
		Element Separator	AN	1			*
	CAS01	Claim Adjustment Group Code	ID	1/2	1033	R	PR
		Element Separator	AN	1			*
	CASE02	Claim Adjustment Reason Code	ID	1/5	1034	R	2
		Element Separator	AN	1			*
	CAS03	Monetary Amount	R	1/18	782	R	Print the Coinsurance Amount
		Segment Terminator					~

 

2430 Line Adjustment CAS – Co-pay

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	CAS	Line Adjustment	ID	3		S	CAS
		Element Separator	AN	1			*
	CAS01	Claim Adjustment Group Code	ID	1/2	1033	R	PR
		Element Separator	AN	1			*
	CASE02	Claim Adjustment Reason Code	ID	1/5	1034	R	3
		Element Separator	AN	1			*
	CAS03	Monetary Amount	R	1/18	782	R	Print the Co-pay Amount
		Segment Terminator					~

2430 Line Adjustment CAS – Insurance Adjustments

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	CAS	Line Adjustment	ID	3		S	CAS
		Element Separator	AN	1			*
	CAS01	Claim Adjustment Group Code	ID	1/2	1033	R	CO
		Element Separator	AN	1			*
	CASE02	Claim Adjustment Reason Code	ID	1/5	1034	R	45
		Element Separator	AN	1			*
	CAS03	Monetary Amount	R	1/18	782	R	Print the Insurance Adjustments
		Segment Terminator					~

 

 

2430 Line Adjustment DTP Line Adjudication Date

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2430	DTP	Line Adjudication Date	ID	3		R	DTP
		Element Separator	AN	1			*
	DTP01	Date/Time Qualifier	ID	3	374	R	573
		Element Separator	AN	1			*
	DTP02	Date time Period Format Qualifier	ID	2/3	1250	R	D8
		Element Separator	AN	1			*
	DTP03	Date time Period	ID	1/35	1251	R	CCYYMMDD
		Segment Terminator					~

Example

SBR*P*18*******CI
AMT*D*52.01
OI***Y***Y
NM1*IL*1*Dianna*Jody****MI*XY31232
N3*4 B Blue Ridge Blvd
N4*Hamilton*OH*45011
NM1*PR*2*FLORIDA BLUE*****PI*BCBSF
LX*1
SV1*HC:99213*195.00*UN*1.00*11**1
DTP*472*RD8*20140905-20140905
REF*6R*219
SVD*BCBSF*52.01*HC:99213**1.00
CAS*PR*2*13.00
CAS*CO*45*129.99
DTP*573*D8*20140905

 

For complete Example, please refer to use case 9,10,12 in the Home page

 

 

 

 

        

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