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Back  RFI # 1521: Remaining Pat Liability 999?

Formal vs. Informal Help Informal Formal

Submitter

Annette Atherton

Description

Is it appropriate for a payer or intermediary to reject with 999 or 277 when the remaining patient liability is NOT present in loop 2430?

Is it the intent of this segment that a provider should calculate the patient remaining liability by adding together all the CAS*PR values for that service line?

If a provider puts an amount that is greater than the sum of the CAS*PR segments will the claim be delayed in processing because the payer now must manually review the difference?

Submitter Assigned Keywords

999 rejection for Remaining Patient Liability 2430 AMT*EAF

Response

The Remaining Patient Liability AMT segment is “Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.” If all of the conditions of the segment Situational Rule are present it would be inconsistent with the TR3 to not send this segment. X12 cannot comment on the appropriateness of a payer or intermediary’s decision to reject a claim.

The intent of this segment is to report the remaining amount to be paid after adjudication by the Other Payer, in the judgment of the Provider.

This segment is for reporting purposes only. It is not part of any transactional balancing requirements. X12 cannot comment on how a payer may react to any data reported in the claim accurate or not.

Because the situational rule for this segment contains the business requirement, "the provider has the ability to report line item information.", using the 999 would not be appropriate.

The 277 Claim Acknowledgment (277CA) Transaction can be used to provide business level acknowledgement for claims (837) accepted for adjudication as well as those that are not accepted. A claim that has a missing or invalid Remaining Patient Responsibility Amount could be rejected out of a payer’s front-end business editing process using the 277CA, if they so choose.

Recommendation

If the 277CA is used to reject a claim as a result of a missing or invalid Remaining Patient Responsibility Amount, it is recommended the payer use the following codes (Claim Status Category, Claim Status and Entity, respectively) to communicate the rejection reason.

Missing amount - A6 (Acknowledgement/Rejected for Missing Information - The claim/encounter is missing the information specified in the Status details and has been rejected), 639 (Responsibility Amount) and QC (Patient).

Invalid amount (based on a payer calculation) – A7 (Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected.), 639 (Responsibility Amount) and QC (Patient).
Submission 2/11/2012
Status Date 5/15/2012
Status F - Final
Primary References
Document 005010X222
SectionClaim
Table2
Loop2430
Segment Position5505
Segment IDAMT