PI98194: CLAIMS PASSING COMPLIANCE WHEN 2430 LOOP IS PRESENT AND SVD01 ISTHE SAME PAYER AS 2330B, INDICATING THAT PAYER HAS ADJUDICATED

APAR status

• Closed as program error.

Error description

• Claims passing compliance when 2430 Loop is present and SVD01 is
  the same payer as 2330B, indicating that payer has adjudicated
  the claim,  and 2320 AMT*D is not present.  The claim should
  fail compliance for the missing AMT*D in 2320
  

Local fix

• ITXCQ - ITX00058830
  LV / LV
  Circumvention: None
  

Problem summary

• Users affected:
  Transformation Extender Pack for Healthcare Payer HIPAA
  
  Problem Description:
  he validation requirement for healthcare claims (837)
  transaction sets that is stated in the TR3 documentation as -
  The Coordination of Benefits (COB) Payer Paid Amount (2320
  AMT_D) segment is required when the claim has been adjudicated
  by the payer associated with the 2320 Other Payer loop and
  identified in the 2330B Other Payer Name loop. - is not being
  enforced by HIPAA X12 Compliance Check.
  
  Platforms affected:
  ALL
  

Problem conclusion

• Code was added to ediexit.cpp and rules.h to implement Rule Type
  52 for 837 claims transaction sets. This new rule type provides
  the capability to check Type 4 rules of the form
  WHEN(PRESENT(2430 SVD FOR 2320 PAYER), PRESENT(2320 AMT_D))
  using COB payer-by-payer matching.
  Rules 59105, 59107, and 59109 were added for 837p, 837i, and
  837d respectively. The new rules have a validation sub-type of
  XT as payer-by-payer matching is not enforced in pre-content
  checking type trees.
  
  These rules have been defined as disabled by default to allow
  the delivery of customer patches without disrupting existing
  customer implementations. This should be changed to enabled for
  the next pack release.
  
  Applies to:
  
  HCIP IP HIPAA 4.4.1.7, Healthcare Payer pack HIPAA
  Fixed in the next service packs and releases.
  
  To obtain the fix for this APAR:
  
  To see if the next service pack or product release is available,
  check the IBM Transformation Extender Downloads page:
  http://www.ibm.com/support/entry/portal/product/other_software/t
  ransformation_extender
  
  If the service pack or product release is available, download it
  from Fix Central:
  http://www.ibm.com/support/fixcentral/
  
  If the service pack or product release is not available and you
  require the APAR fix immediately, request a Limited Availability
  Interim Fix (LAIF) by opening a PMR:
  http://www.ibm.com/support/servicerequest/Home.action
  
  Prior to version 9.0.0, IBM Transformation Extender was called
  IBM WebSphere Transformation Extender.
  

Temporary fix

Comments

APAR Information

• APAR is sysrouted FROM one or more of the following:

• APAR is sysrouted TO one or more of the following:

Fix information

• Fixed component name

  TX HIPPA EDI

• Fixed component ID

  5724M6100

Applicable component levels