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Back  RFI # 1634: Use of Patient Amount Paid

Formal vs. Informal Help Informal Formal

Submitter

Kim Oberbroeckling

Description

A payer that is a Medicare Advantage Organization is requiring that providers populate the Patient Amount Paid segment (AMT, qualifier F5) in the 2300 loop of the 837 with the patient's estimated liability.

According to the 5010 837 TR3, the Patient Amount Paid segment 'refers to the sum of all amounts paid on the claim by the patient or his or her representative(s)'.

The payer said that the Patient Amount Paid segment should be populated with an amount is based on the member's benefit plan and not what was paid.

Is this an appropriate use of the Patient Amount Paid?

Submitter Assigned Keywords

5010 TR3 Patient Amount Paid AMT02 2300 loop

Response

It is not appropriate to use the Payer Paid segment for amounts that the patient has not paid. The Situational Rule for this segment reads, “Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.” If the patient has not actually made a payment toward this claim, this segment must not be sent.
Submission 7/23/2012
Status Date 9/11/2012
Status F - Final
Primary References
Document 005010X222
Section2.4
Page190
Set ID837
Table2
Loop2300
Segment Position1750
Segment IDAMT
Element Position02