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Submitter

Peter Anderson

Description

We are trying to satisfy the TR3 requirements for the 2100/AMT*AU (covered amount) which is defined as 'the amount of the original provider submitted charges that are considered for payment under the benefit provisions of the health plan.' Some claims that result in an advance payment to the provider are appropriately received with zero submitted charges, Is it appropriate to report the allowed charge as the covered charge in this situation, even though the allowed charge exceeds the 'original provider submitted charges?'

Response

The 2100 AMT01 qualifier AU (Coverage Amount) TR3 note states "This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered...." That specifically identifies this as the "original submitted provider charges". Within the 2110 loop, there is a separate AMT01 qualifier B6 (Allowed - Actual) for the allowed amount.

As a result, it is not appropriate to report the allowed charge as the covered charge. If the provider submitted charge is 0.00, then that is the covered amount. Since the situational rule for the 2100 AMT states "Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.", the AMT*AU segment is not conveyed in this situation
Submission 5/23/2014
Status Date 7/1/2014
Status F - Final
Primary References
Document 005010X221A1
Section2
Page182
Set ID835
Table2
Loop2100
Segment Position620
Segment IDAMT
Element Position02
Industry NameClaim Supplemental Information Amount