Parsing an 835 remit: CLP, CAS, PLB and payment matching

An 835 arrives. The BPR payment total does not equal the sum of the CLP04 paid amounts. The file is correct. The difference sits in a PLB segment near the end, and your parser skipped it.

The standard and the rules

HIPAA adopts the X12 835, version 005010X221, as the remittance standard in 45 CFR 162.1602. The same section adopts the NACHA CCD+ with the 835 TRN segment in its addenda record as the EFT standard. 45 CFR 162.1603 adopts the CAQH CORE Phase III rules 350, 360, 370, 380 and 382, in force since January 1, 2014.

Header: BPR and TRN

After the ISA, GS and ST envelope, BPR carries the payment. BPR02 is the total amount, BPR03 the credit or debit flag, BPR04 the method (ACH, CHK or NON) and BPR16 the effective date. TRN carries the trace: TRN01 the trace type, TRN02 the EFT trace number, TRN03 the payer identifier. The CORE reassociation rule names TRN02 as the only number that matches an EFT to its 835; the bank overwrites the ACH trace number. The same rule requires the 835 to be released no sooner than three business days before, and no later than three business days after, the CCD+ effective entry date. It treats an EFT or ERA as late or missing four business days after the other one arrives.

Loop 1000A names the payer and 1000B the payee. The CMS 835 companion guide shows REF with qualifier TJ in 1000B carrying the payee tax ID.

The CLP loop

Each claim is one 2100 loop that opens with CLP.

CLP*A1234*1*250*180*20*MB*2512345678901*11*1~

• CLP01: the patient control number you sent in 837 CLM01. This is your primary match key.
• CLP02: claim status code. 1 processed as primary, 2 as secondary, 3 as tertiary, 4 denied, 22 reversal of a previous payment. The CGS Medicare 835 companion guide lists 1, 2, 3, 4, 19, 20, 21, 22 and 23 as the values Medicare sends, and notes that 25, predetermination pricing only, does not apply to Medicare.
• CLP03 total charge, CLP04 paid, CLP05 patient responsibility.
• CLP06 claim filing indicator. Medicare sends MA for Part A and MB for Part B.
• CLP07 payer claim control number. Store it. The 276 and appeals use it.
• CLP08 facility type code and CLP09 claim frequency code.

NM1 segments name the patient (QC), the insured (IL) and a corrected name (74). Medicare sends MI as the patient identifier qualifier. REF segments carry other claim identifiers; Medicare uses qualifiers 28, 6P, CE, EA and F8 (CGS guide). Then one 2110 loop per service line opens with SVC: SVC01 the procedure code with qualifier HC for CPT and HCPCS, SVC02 the line charge, SVC03 the line paid amount, SVC05 units. DTP 472 is the service date. A REF segment echoes the line item control number you sent in 837 2400 REF02.

CAS adjustments

CAS explains the gap between charge and payment. It appears at claim level in 2100 and at line level in 2110. CAS01 is the group code. CAS02, CAS03 and CAS04 are the first reason code, amount and quantity, and the triple repeats within the segment.

The group codes are CO contractual obligation, OA other adjustment, PI payor initiated reduction and PR patient responsibility. Medicare contractors use only CO, OA and PR; PI is not used (CMS guide).

Reason codes come from the CARC list. The ones you will post most: 1 deductible, 2 coinsurance, 3 copayment, 45 charge exceeds the fee schedule, 18 exact duplicate (with group OA), 22 covered by another payer under coordination of benefits, 16 claim lacks information, 50 not medically necessary, 96 non-covered charge, 97 benefit included in another service, 197 authorization absent, 204 not covered under the plan, 253 sequestration. RARC codes in LQ segments with qualifier HE add detail to a CARC. Informational RARCs carry the prefix Alert and are not tied to an adjustment.

The CORE 360 rule defines four business scenarios: additional information required, missing or invalid claim data, service not covered, and benefit not separately payable. For each it limits the CARC, RARC and group code combinations a plan may use. A plan may add scenarios beyond those four. The rule also notes that the X12 lists change several times a year, so load the codes from the source instead of a copy.

Balance before you post. For each line, SVC02 minus the sum of its CAS amounts equals SVC03. For each claim, CLP03 minus claim-level and line-level CAS amounts equals CLP04. CLP05 equals the sum of the PR group amounts. Reject a file that does not balance and log which claim broke it.

PLB

PLB sits after the last CLP loop and before SE. It adjusts the payment at provider level, outside any claim. PLB01 is the provider identifier, PLB02 the fiscal period date, then pairs of reason code and amount. The codes come from the provider adjustment reason code list: WO overpayment recovery, FB forward balance, L6 interest, 72 provider refund, IR 1099 withholding, CS adjustment explained separately, AP advanced payment, 50 late filing penalty. The CMS guide lists the codes Medicare sends, including WO, FB, L6, 72 and CS. A positive PLB amount reduces the payment. A negative amount increases it. The reason code composite carries a reference, often the payer claim control number of the claim being recouped.

The file balances when BPR02 equals the sum of all CLP04 minus the sum of all PLB amounts.

Matching back to the practice management system

1. Match on CLP01. Your system generated it as CLM01. Compare after trimming and upper-casing.
2. If CLP01 fails, match CLP07 against the payer claim control number stored from the 277CA or an earlier 835.
3. If both fail, match on the patient's last name and member ID from NM1 QC, the service dates from DTP 472 and the charge in CLP03.
4. Match lines on the echoed line item control number, then on procedure code, modifier and date.
5. For CLP02 22, find the original posting and reverse it.
6. Post PR amounts to the patient balance by reason code. Post CO and OA as adjustments. Post PI as an adjustment with a flag, because it is a payer decision you can dispute.
7. Post each PLB as a payment-level transaction, linked to the recouped claim when the reference names it.

Store the raw 835 and TRN02 with every posting. When the deposit arrives, match TRN02 to the CCD+ addenda and close the loop. Before you trust a practice management system's ERA import, check how it handles PLB and CLP02 22.