Charge Balancing

All claims must have the charges in balance according to a completely straightforward principle:

• The Total Claim Charge Amount in CLM02 must be equal to the sum of all Line Item Charge Amount elements reported in the SV segment(s) of the claim.

Coordination of Benefits Balancing

There are additional balancing requirements in Coordination of Benefits (COB) claims – those claims in which one or more prior payers are involved. Although there can be some complexity in the details, COB claims balancing can be described as follows:

• Each payer must show payments plus adjustments equal to charges.

Here are some additional guidelines that can be followed (please refer also to Section 2.2.1 of the 835 Implementation Guide):

• Loop 2320, with its sub-loops 2330A and 2330B, is required for all payers potentially involved in adjudicating the claim.
• A prior payer's claim-level payment and adjustment(s) should be reported at the claim level.
• A prior payer's line-level payment and adjustment(s) should be reported at the line level.
• For a primary payer that has adjudicated the claim, the payment must be reported in an AMT segment in Loop 2320 (AMT*D in the 837 Professional and 837 Dental; AMT*C4 in the 837 Institutional). The amount in AMT02 must equal the Total Claim Charge Amount in CLM02 minus the sum of the adjustments reported in all claim and line level CAS segments for that payer.
• When a prior payer made line-level payments, they are reported in SVD segments. The sum of that payer's SVD02 Service Line Payment Amount elements is the amount carried in AMT*D or AMT*C4. That payer is identified in element SVD01 by the same value that was sent in element NM109 of the iteration of loop 2330B that identified that payer.