Some payors make modifications to the claim data when claims are processed. One example of this is when a CPT code used for billing is not recognized by the payor. The payor may then modify the code being returned in the ERA file to a generic code. When this happens the system would generally reject the ERA transaction because the CPT code that is now being referenced in the 835 is not a match to the CPT code on the patient's ledger.
To avoid this issue, the system has logic built into the ERA program to look at various segments of the SVC charge loop to identify the code to use for matching purposes.
System will look for a valid CPT code in the SVC segment 06
If there is no segment 06 the system will look to segment 07
If no code is found in segment 07 it will then look to segment 01
| Transaction Examples | |
| SVC|HC^99199|8000|1140|0490|0|HC^45378 | System would use the 45378 code found in segment 06 |
| SVC|HC^45378|4000|1474.3|0490|1 | System would use 45378 code found in segment 01 |
| SVC|HC^00810^AA^PT^QS|2450|130.46||1.8||27 | System would use 00810 code found in segment 01 |
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