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Back  RFI # 1353: Coordination of benefits

Formal vs. Informal Help Informal Formal

Submitter

Christian Lawrence

Description

I need some clarification on the situational fields in loop 2320 specifically around the the new AMT fields (Remaining Patient Liability and Total Non-Covered Amounts). The usage say they are situational but the situational rules are what get me. Is it saying that if the data has been provided in the 835, then you may provide this information but you won't get a denial if you fail to send it OR if the claim has been adjudicated (has a CAS segment), then these segments are mandatory?

Submitter Assigned Keywords

5010 AMT Remaining Patient Liability Total Non-Covered Amounts

Response

The remaining patient liability amount is required when the other payer has reported only claim level adjudication information (either paper or electronic) and in the judgment of the provider this is the remaining amount to be paid after adjudication from the other payer; this amount is only used in provider to payer COB situations.

The total non-covered amount segment is required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. It is used when the prior payer is not billed because the destination payer’s policy allows providers to submit the claim without the prior payer’s adjudication information. This only applies when there is no 835 or paper remittance from the prior payer.
Submission 7/6/2011
Status Date 8/9/2011
Status F - Final
Primary References
Document 005010X223
Section1.4.1.1
Page365
Table2
Loop2320
Segment Position3000
Segment IDAMT