Tip: Versioning for 71420 and 79413D

0017

71420,79413D

01 Mar 2019

 28 Mar 2022

Added example:

SEs 71420 and 79413D utilize a custom versioning application that does NOT replace claim lines with changes or replacements. 

To find total costs for the claim, all claim lines must be aggregated. The user would sum all values in the cost fields across all rows with the same claim number (MC004) and claim line (MC005) to get total claim line cost.

The example below illustrates this approach. Claim line 1 for claim OEB00053171 has two rows, one with paid date 9/4/2018 and the second with paid date 2/28/2019. The paid amount for the claim line where paid date = 9/4/2019 is $2067.38. The paid amount for the claim line where paid date = 2/28/2019 is ($2067.38). Sum these two paid amounts to get the overall claim line paid amount of $0.00. Claim status (MC138) appears to indicate adjustments however it cannot be relied upon consistently to indicate adjustments.

The same approach should be used for all $ fields. The example below includes co-pay and deductible, too.

DSG

Versioning

Tip

Claims

Claim Number (MC004)

Claim Line (MC005)

Paid Date (MC017)

 Paid Amount (MC063) 

 Co-Pay (MC065) 

 Co-insurance (MC066) 

 Deductible (MC067) 

Claim Status (MC138)

OEB000531711700

1

9/4/2018

 $                            2,067.38

 $                                    -  

 $                                      -  

 $                                  -  

O

OEB000531711700

1

2/28/2019

 $                          (2,067.38)

 $                                    -  

 $                                      -  

 $                                  -  

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -  

OEB001380589000

13

9/12/2019

 $                            3,711.55

 $                           200.00

 $                                      -  

 $                                  -  

O

OEB001380589000

13

11/26/2019

 $                          (3,711.55)

 $                         (200.00)

 $                                      -  

 $                                  -  

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -  

KEN003200325100

1

3/12/2020

 $                                         -  

 $                                    -  

 $                                      -  

 $                           69.37

O

KEN003200325100

1

7/2/2020

 $                                         -  

 $                                    -  

 $                                      -  

 $                        (69.37)

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -  

KEN003200325100

2

3/12/2020

 $                                         -  

 $                                    -  

 $                                      -  

 $                           90.43

O

KEN003200325100

2

7/2/2020

 $                                         -  

 $                                    -  

 $                                      -  

 $                        (90.43)

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -  

ATL002502087200

1

2/6/2020

 $                                     0.49

 $                                    -  

 $                                      -  

 $                           49.28

O

ATL002502087200

1

4/13/2020

 $                                  (0.49)

 $                                    -  

 $                                      -  

 $                        (49.28)

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -  

OEB000476134000

12

8/3/2018

 $                            1,575.14

 $                           200.00

 $                                      -  

 $                        279.90

O

OEB000476134000

12

10/11/2018

 $                          (1,575.14)

 $                         (200.00)

 $                                      -  

 $                      (279.90)

A

Claim Line Total

 $                                         -  

 $                                    -  

 $                                      -  

 $                                  -