DRG and Deductible Info Not Showing up in CSV file
infor...@com1software.com
We we able to find a problem with some claim level fields were picking up service level
information. It should be fixed in version Version 1.17B-18.
I appreciate your help and patience in finding this problem.
Thanks
Dave
Let my try to explain this again using one outpatient record from the 835 file and then
compare it to what the x-12 utility is generating. Ultimately, I need to balance, Claim Total
minus Adjustments = Claim Total Paid.
Record 10 in the 835 file is below. ( I am using this record because it only has two
adjustments )
I only see two CAS segments:the first has an amount of 161.39 and the second at 36.2. The
total billed amount is 255.00the total paid amount is 57.41.
total billed amount 255.00 minus CAS 161.39 minus CAS 36.2 =total paid amount 57.41.
Which I see below.
CLP*XXXXXXX*19*255*57.41**MA*MIA*13*1~
NM1*QC*1*LNAME*FNAME****HN*XXXXXXXXXA~
NM1*TT*2*BCBS*****PI*XXXXXXX7~
MOA*.35**MA01~
REF*EA*700234~
DTM*050*20100617~
DTM*232*20100518~
DTM*233*20100518~
AMT*DY*.35~
AMT*AU*255~
SVC*HC>76536*255*57.41*0402*1~
DTM*472*20100518~
CAS*CO*45*161.39~
CAS*PR*2*36.2~
REF*1S*00266~
AMT*B6*255~
Now if you open up the excel file that has just numbers and no identifying information. I have
highlighted record 10. Now when I do the calculation from the numbers I see in the X-12
utility output:
CLAIMTOTALCHARGE (255) MINUS CLMADJAMT1 (161.39) MINUS CLMADJAMT2 (
36.2) MINUS PROCADJAMT1.1 ( 161.39 ) MINUS PROCADJAMT1.2 ( 36.2 ) = total paid
amount-140.18 This is incorrect. It should total CLAIMTOTALPAID (57.41)
I only see two CAS statements in the above claim record. The output file states there are
four.
You can also look at claim record #11 and do the balancing calc. The total billed minus all
the adjustments does not equal the total paid.
What do I need to do to get the output file to tie to: Total Billed minus Adjustments = Total
Paid Or Total Billed = Total Paid plus all the Adjustments ?
This needs to be clean in the output file with no manipulation after the file is created by the X-
12 Utility.
Phil
Com1 Software
Philip LaRochelle
The update did the trick. I am now able to tie out and or balance: Claim Total minus Adjustments = Claim Total Paid.
Moving on I have something else that I need you to look at. It appears that when a claim is not paid Zero dollars or a claim is a "take back" a negative number in the CLAIMTOTALPAID column the PRIMARYPAYERCLAIMCODE does not populate:
The attached excel file shows the X-12 utility output, again I have provided just numbers with no identifying information. The highlighted rows show that the PRIMARYPAYERCLAIMCODE column is empty when the CLAIMTOTALPAID cell within a record is either zero or a negative number.
The 835 file data is that of record 1 without any identifying information.
The CLP segment shows that there is a PRIMARYPAYERCLAIMCODE which ends in MIA. As you can see the totals here reflect what is in the output file.
CLP*15*22*-9736.7*-4039.85**MA*XXXXXXXXXXXXXXMIA*11*8**293*-.694*-1~
CAS*CO*45*-5696.85~
NM1*QC*1*FNAME*LNAME****HN*XXXXXXXXX1A~
MIA*0***-4039.85*MA02*-262.57**-285.69*-285.69******-4*-3491.59~
REF*EA*548744~
DTM*050*20100329~
DTM*232*20100202~
DTM*233*20100206~
AMT*AU*-9736.7~
QTY*CA*-4~
SVC*NU>0110*-2676*-2676**-4**4~
DTM*472*20100206~
AMT*B6*-2676~
SVC*NU>0250*-8*-8**-1**1~
DTM*472*20100206~
AMT*B6*-8~
SVC*NU>0251*-880.99*-880.99**-1**1~
DTM*472*20100206~
AMT*B6*-880.99~
SVC*NU>0252*-65.71*-65.71**-1**1~
DTM*472*20100206~
AMT*B6*-65.71~
SVC*NU>0300*-1004*-1004**-1**1~
DTM*472*20100206~
AMT*B6*-1004~
SVC*NU>0301*-611*-611**-1**1~
DTM*472*20100206~
AMT*B6*-611~
SVC*NU>0305*-219*-219**-1**1~
DTM*472*20100206~
AMT*B6*-219~
SVC*NU>0306*-260*-260**-1**1~
DTM*472*20100206~
AMT*B6*-260~
SVC*NU>0307*-29*-29**-1**1~
DTM*472*20100206~
AMT*B6*-29~
SVC*NU>0324*-240*-240**-1**1~
DTM*472*20100206~
AMT*B6*-240~
SVC*NU>0351*-850*-850**-1**1~
DTM*472*20100206~
AMT*B6*-850~
SVC*NU>0421*-164*-164**-1**1~
DTM*472*20100206~
AMT*B6*-164~
SVC*NU>0424*-135*-135**-1**1~
DTM*472*20100206~
AMT*B6*-135~
SVC*NU>0434*-135*-135**-1**1~
DTM*472*20100206~
AMT*B6*-135~
SVC*NU>0450*-632*-632**-2**2~
DTM*472*20100206~
AMT*B6*-632~
SVC*NU>0480*-1432*-1432**-1**1~
DTM*472*20100206~
AMT*B6*-1432~
SVC*NU>0730*-395*-395**-1**1~
DTM*472*20100206~
AMT*B6*-395~
Thanks,
Phil
Also is the X-12 Utility, X-12 Version 5010 compliant?
From: "infor...@com1software.com" <infor...@com1software.com>
To: x12-u...@googlegroups.com
Sent: Wed, March 2, 2011 2:28:58 PM
Subject: DRG and Deductible Info Not Showing up in CSV file
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Com1 Software
The reason the PRIMARYPAYERCLAIMCODE is not populated is due to the
Claim Status Code is a 22 and not a 19.
In looking at our documentation:
http://com1software.com/c1d0f431.htm#0612
I need to make some improvements to better reflect the qualifiers
involved in the field operation.
We may also need to add some additional fields to our export
capability.
Below is the list of applicable status codes:
Thanks
Dave
1 Processed as Primary
2 Processed as Secondary
3 Processed as Tertiary
4 Denied
5 Pended
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
10 Received, but not in process
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
13 Suspended
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
15 Suspended - investigation with field
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
16 Suspended - return with material
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
17 Suspended - review pending
NOT ADVISED
1266 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
19 Processed as Primary, Forwarded to Additional
Payer(s)
20 Processed as Secondary, Forwarded to Additional
Payer(s)
21 Processed as Tertiary, Forwarded to Additional
Payer(s)
22 Reversal of Previous Payment
23 Not Our Claim, Forwarded to Additional Payer(s)
25 Predetermination Pricing Only - No Payment
27 Reviewed
NOT ADVISED
1389 Claims with this status should be reported in the
Claim Status (277) transaction when the payer
implements it.
> export12.xls
> 34KViewDownload
Philip LaRochelle
From: Com1 Software <infor...@com1software.com>
To: X12 Utility <x12-u...@googlegroups.com>
Sent: Mon, March 7, 2011 12:28:53 PM
Subject: Re: DRG and Deductible Info Not Showing up in CSV file
> For more options, visit this group athttp://groups.google.com/group/x12-utility?hl=en.
>
> export12.xls
> 34KViewDownload
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infor...@com1software.com
If need be PAYERCLAIMCODE will give element 7 of the CLP and
CLAIMSTATUSCODE will give element 2 of the same with no
qulaifications to elemnt 2.
On 7 Mar 2011 at 9:41, Philip LaRochelle wrote:
>
> Dave,
>
> When reviewing thecomplete file I also see a Claim Satus Code of 4
> (Denied) as another
> instance of records not being populated with a
> PRIMARYPAYERCLAIMCODE. Is this the same
> issue withthe 22 Claim Satus Code explained below?
> > x12-utility...@googlegroups.com.
> > For more options, visit this group
> athttp://groups.google.com/group/x12-utility?hl=en.
> >
> > export12.xls
> > 34KViewDownload
>
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Philip LaRochelle
If I am comprehending your last reply.
Is there is a reason or example on why one of the codes needs to qualify the other? I see this utility as a data dump from the 835. I am sure there are more complexities that I have not ran across that might need certain " if - then " reasoning. If this is one of those cases then I will have to live with what is programmed.
If this can be just set up as reading each PAYERCLAIMCODE and CLAIMSTATUSCODE and export them without any qualification that would be great.
Phil
From: "infor...@com1software.com" <infor...@com1software.com>
To: x12-u...@googlegroups.com
Sent: Mon, March 7, 2011 12:49:30 PM
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Philip LaRochelle
Claim Supplement Information
Loop: 2100 - CLAIM PAYMENT INFORMATION
1. Use this segment to convey information only. It is not part of the financial balancing of the 835.
2. Use this segment only when the value of specific amount identified in the AMT01 qualifier are Non-Zero.
Segment: AMT
Data Segment: 522
Level: detail
position: 062
loop: 2100
requirement: optional
max use: 20
purpose: to indicate the total monetary amount.
What I really need reported is the "AU" code," Coverage Amount" and monetary amount.. It is my understanding that Coverage Amount is different than ClaimTotalPaid.
Below is where the segment is located in the claim record. It appears to be in all records not just IP or OP. All PII data has been removed.
AMT*AU*248~
CLP*1148916701*1*248*62.34**MA*XXXXXXXXXXXXMIA*13*1~
NM1*QC*1*LNAME*FNAME*MI***HN*XXXXXXXXXXXXA~
MOA*.35*62.34*MA01~
REF*EA*504312~
DTM*050*20100617~
DTM*232*20100519~
DTM*233*20100519~
AMT*DY*.35~
AMT*AU*248~
SVC*HC>36415*18*3*0300*1~
DTM*472*20100519~
CAS*CO*45*15~
AMT*B6*18~
SVC*HC>80048*72*9.63*0301*1~
DTM*472*20100519~
CAS*CO*45*62.37~
AMT*B6*72~
SVC*HC>80061*62*14.53*0301*1~
DTM*472*20100519~
CAS*CO*45*47.47~
AMT*B6*62~
SVC*HC>84443*60*24.06*0301*1~
DTM*472*20100519~
CAS*CO*45*35.94~
AMT*B6*60~
SVC*HC>85025*36*11.12*0305*1~
DTM*472*20100519~
CAS*CO*45*24.88~
AMT*B6*36~
Thanks,
Phil
From: "infor...@com1software.com" <infor...@com1software.com>
To: x12-u...@googlegroups.com
Sent: Mon, March 7, 2011 12:49:30 PM
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