Change Request Detail
No.
1146
Date
2/4/2011
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
Have Claim Level Payment amouts equal the total of payments reported at the service level to aid in the processing of and the balancing of remittance transactions.  United Healthcare now reports the total they are remitting at the claim level, but payments already made by others are include in the file at the service level.
Suggestion
Have the specifiactions state that the payment amount at the claim level equals to the total of the payments reported on all services.  The service level payments should only inlcude the amounts from the payer creating the remittance file
DSMO Category
D
Recommendation
Disapprove.  Section 1.10.2.1 of the 005010 835 TR3 and Section 1.4.4 of the 005010 837 TR3 explain how balancing and coordination of benefits are to be done.  If the requester continues to have questions, he should submit a Request for Interpretation to the X12 portal at http://www.x12.org/x12org/subcommittees/x12rfi.cfm

Appeal Recommendation