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Scenario:

The Outbound 837P, completed in Exercise 1, was sent on to Blue Cross the payer. The Claim was adjudicated and Blue Cross has transmitted the 835 5010A1 transaction directly to the receiving billing provider, Abuncha Physicians.

Within the transaction are also two additional claims for the same patient, from claims sent previously.

Check #: EFT20160114006979 dated: 01/14/2016 Check total: $85.25 Deposit (ACH)

The objective here is to translate the Inbound 835 005010X221A1 transaction and fill in the missing data, EOB payments and adjustments.

Supporting Information:

CLP01 Claim Submitter ID (Same as CLM01 on submitted 837) aka Patient Acct. No or Invoice

CLP02 Claim Status Codes:

  • 1 - Paid as Primary
  • 4 – Denied

CLP03 Claim Charge Amount

CLP04 Claim Paid Amount

CLP05 Patient Responsibility Amount

Claim Adjustment Group Code, CAS01:

  • PR - Patient Responsibility
  • CO - Contractual
  • PI – Payer Initiated

Claim Adjustment Reason Codes CAS02,05,08 etc:

  • 3 - Copay
  • 15 - The authorization number is missing, invalid or does not apply to the billed services or provider.
  • 45 - Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
  • B7 - This provider was not certified/eligible to be paid for this procedure/service.
  • (External Codes available at http://www.wpc-edi.com/codes)

AMT*B6 specifies Allowed Amount (informational, not used for balancing)

ISA*00* *00* *ZZ*BCBS_FL *ZZ*ABUNCHA *110114*1150*^*00501*000000001*0*P*:~
GS*HP*BCBS_FL*ABUNCHA*20160114*1150*1*X*004010X091A1
ST*835*0001~
BPR*I*105.5*C*ACH*CCP*01*099000025*DA*170999028999*111234567**01*1111234567*DA*1122334455*20160114~
TRN*1*EFT20160114006979*741234*1116754321~
DTM*405*20160112~
N1*PR*BLUECROSS BLUESHIELD~ Payer
N3*P.O. BOX 12345~
N4*ORLANDO*FL*334131234~
PER*CX**TE*8006655044~
N1*PE*ABUNCHA PHYSICIANS*XX*4121212121~ Payee
N3*PO BOX 12333~
N4*MIAMI*FL*33111~
REF*TJ*1111234567~ Payee Tax ID
LX*1~
CLP*A126462967*1*100*55.25*10*HM*BCBS_CLAIM12*11~1st Claim (Paid as Primary CLP02 = 1)
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM12~
DTM*050*20160112~
SVC*HC:99213*40*30**1~ Service 1
DTM*472*20101116~ Service Date
CAS*PR*3*10~ Adjustment
REF*6R*20001~ Provider Line Item number
AMT*B6*40~ Allowed Amount
SVC*HC:95010*15*9.75**1~ Service 2
DTM*472*20101116~
CAS*CO*45*5.25~
REF*6R*20002~
AMT*B6*15~
SVC*HC:87072*35*0**1~ Service 3
DTM*472*20101116~
CAS*PI*15*35~
REF*6R*20003~
AMT*B6*35~
SVC*HC:86663*10*6**1~ Service 4
DTM*472*20101116~
CAS*CO*45*4~
REF*6R*20004~
AMT*B6*40~
LX*2~
CLP*A126462960*4*15*0**HM*BCBS_CLAIM11~2nd Claim (denied)
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM11~
DTM*050*20160107~
SVC*HC:T1013*15*0**1~ Service 1
DTM*472*20101107~
CAS*CO*B7*15~
REF*6R*19006~
LX*3~
CLP*A126462910*1*45.5*35.5*10*HM*BCBS_CLAIM08~3rd Claim
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM08~
DTM*050*20160106~
SVC*HC:99213*45.5*35.5**1~ Service 1
DTM*472*20101101~
CAS*PR*3*10~
REF*6R*19002~
AMT*B6*45.5~
SE*63*0001~
GE*1*1~
IEA*1*000000001~

Select the best answer for each question:

1. Claim 1 Service Date (DTM02 where DTM01 = 472)


 
2. Claim 1 - 3rd service procedure code (SVC01-2)


 
3. Claim 1 - 3rd service charge amount (SVC02)


 
4. Claim 1 - 3rd service paid amount (SVC03)


 
5. Claim 1 Total Paid (CLP04)


 
6. Claim 2 Claim Status (CLP03)


 
7. Claim 2 Transaction Check or EFT Trace Number (TRN02)


 
8. Claim 2 Claim Submitter ID (Invoice or Patient Control Number) (CLP01)


 
9. Claim 2 Payer Trace Number (CLP07)


 
10. Claim 2 Allowed Amount (AMT02 where AMT01 = B6)


 
11. Claim 3 Service Date (DTM02 where DTP01 = 472)


 
12. Claim 3 Allowed Amount (AMT02 where AMT01 = B6)


 
13. Claim 3 Patient Responsibility Amount (CLP05)


 

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