835 Remittance Details
The processing of an 835 remittance file for an NCPDP claim is accomplished by calculating the myAvatar claim number from the prescription number provided in the 835 (2100-CLP-01).
The following logic is used:
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The prescription number is used to look up the patient ID and the associated services.
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The service dates (2100-DTM) are used to create a date range of services to check. This could possibly result in an exact date match.
For each service within this range, the liability breakdown is checked to identify each guarantor and corresponding liability. The claim number for each liability entry and all re-billed claims stemming from that claim are identified.
The guarantor and claim number are then recorded as potential choices under the following conditions:
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If it is a reversal (claim status code [2100-CLP-02] is 22), the information is recorded only if the claim and service have a payment.
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If it is a payment (claim status code is not 22), the information is recorded only if one of the payments (for this claim or this service) has not occurred.
After looping through all services in the range, there may be multiple guarantors and claims. If applicable, crossover payment logic is utilized on the fields in the 835 section of the Guarantor/Program Billing Defaults form.
The following logic is used:
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For every remaining candidate guarantor, the two identification fields on this tab are examined: Payor Name (1000A-N1-02) and Payee Identification Code (1000B-N1-04). If they are populated, these values are compared to the corresponding locations within the 835 file being processed. Any mismatching guarantors are discarded.
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If there are still multiple guarantors, an error will be recorded on the report.
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If there is only one guarantor, but multiple claims remain:
For a reversal (claim status code [2100-CLP-02] is 22), the last claim is used. This represents the most recent paid claim for the guarantor.
For a payment (claim status code is not 22), the first claim is used. This represents the first unpaid claim for the guarantor.
The selected claim is then used and the 835 remittance is processed.