If the 837 File contains optional fields (data elements) that may create optional segments, will the file pass the 997 structural edits?
Yes, situational segments can be transmitted, page 77 of the California Implementation guide states “O = Optional The data element is sent if available. If the data element is sent the data edits are applied to the optional data element and situational segments.” Q. Clarify the need for both Bill Adjustment Group Codes (DN543) & Bill Adjustment Reason Codes (DN 544) versus Service Adjustment Group Codes (DN731) & Service Adjustment Reason Codes (DN 732). For pharmacy, it is our understanding that we will only need to report at the service level and not the bill level – – would this be correct? A: No. The California bill and line CAS segment mandatory triggers are “If paid amount is not equal to billed amount” If an adjustment occurs at the line it must occur at the bill level (sum of the line totals equals the bill total). A line level adjustment cannot occur without a bill level adjustment. If the sender sends one line per bill then the line level adjustment equals the bill level adju
