Claim edit: COB service lines must be balanced
Stedi now rejects 837P professional, 837D dental, and 837I institutional claims sent to a non-primary payer when a service line's coordination of benefits (COB) amounts don't balance.
How the edit works
When a patient has multiple insurance plans, the provider submits a claim to each payer in order. The first is the primary payer. Any that follow are secondary, tertiary, and so on. This process is called coordination of benefits (COB).
A service line is a line item for a specific service on a claim, like an office visit or X-ray.
When you submit a claim to a non-primary payer, you must include each previous payer's adjudications – their payments and adjustments. Include both claim-level and service line-level adjudications from each prior payer. Don't include the same amounts at both levels.
Balancing service lines
When you include prior payer adjudications at the service line level, the amounts must add up as follows:
Billed line charge
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].professionalService.lineItemChargeAmount | SV1-02 (Line Item Charge Amount) of Loop 2400 (Professional Service) |
| 837D dental | claimInformation.serviceLines[].dentalService.lineItemChargeAmount | SV3-02 (Line Item Charge Amount) of Loop 2400 (Dental Service) |
| 837I institutional | claimInformation.serviceLines[].institutionalService.lineItemChargeAmount | SV2-03 (Line Item Charge Amount) of Loop 2400 (Institutional Service) |
Prior payer line paid amount
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].lineAdjudicationInformation[].serviceLinePaidAmount | SVD-02 (Service Line Paid Amount) of Loop 2430 (Line Adjudication Information) |
| 837D dental | claimInformation.serviceLines[].lineAdjudicationInformation[].serviceLinePaidAmount | SVD-02 (Service Line Paid Amount) of Loop 2430 (Line Adjudication Information) |
| 837I institutional | claimInformation.serviceLines[].lineAdjudicationInformation[].serviceLinePaidAmount | SVD-02 (Service Line Paid Amount) of Loop 2430 (Line Adjudication Information) |
Line adjustment amounts
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails[].adjustmentAmount | CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, and CAS-18 of Loop 2430 (Line Adjudication Information) |
| 837D dental | claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails[].adjustmentAmount | CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, and CAS-18 of Loop 2430 (Line Adjudication Information) |
| 837I institutional | claimInformation.serviceLines[].lineAdjudicationInformation[].lineAdjustment[].claimAdjustmentDetails[].adjustmentAmount | CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, and CAS-18 of Loop 2430 (Line Adjudication Information) |
If the amounts don't balance for any service line adjudication, the payer may reject the claim.
This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which are slower and delay payment for the provider.
We previously added a separate edit for claim-level COB balancing.
Rejection errors
If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:
{
"errors": [
{
"code": "33",
"description": "Coordination of Benefits (COB) balancing failed. For line 1, the total charged amount of $150.00 does not equal the sum of the paid amount of $0.00 and all adjustment amounts of $200.00 for payer STEDITEST. Correct and resubmit.",
"followupAction": "Please Correct and Resubmit"
}
]
}If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, and error message:
STC*A7>551*[DATE]*U*[AMOUNT]********Coordination of Benefits (COB) balancing failed. For line 1, the total charged amount of $150.00 does not equal the sum of the paid amount of $0.00 and all adjustment amounts of $200.00 for payer STEDITEST. Correct and resubmit.~