Change Request Detail
No.
1188
Date
4/19/2013
Submitter
Type of Request
Professional Claim (HCFA 1500)
Status
DSMO Process Completed
Business Reason
From the response to ASC X12 RFI #1772, "SV2 # of service lines" ...

"Guide 005010X221 (Health Care Claim Payment/Advice) section 1.10.2.11 (Claim Splitting) describes how a health plan may split an incoming claim into multiple claims. This process allows a health plan to receive a single claim with, for example - 50 service lines, and split that into multiple claims, for example 2 claims of 22 service lines and 1 claim of 6 service lines.  So, if the payer can only adjudicate a subset of the 999 service lines (22 as indicated by the RFI submitter) a compliant approach is available."

The explanation above does not seem to exist in any of the version 005010 Health Care Claim TR3s:  005010X222, 005010X223, and 005010X224.  It would be very useful if a generalized version of the above language was directly included into future versions of the Health Care Claim TR3s.
Suggestion
As applicable / appropriate in front matter similar to version 005010X222 1.4.1.4.
DSMO Category
C
Recommendation
Approve. ASC X12 has already addressed claim and line splits as applied to COB claims in the next version of the Health Care Claims Guides.
Appeal Recommendation