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Back  RFI # 292: Approved vs Allowed Amount

Formal vs. Informal Help Informal Formal

Submitter

Doreen Espinoza

Description

While cross walking from the 835 to the 837 Professional we found that there is a possible conflict of terminology which makes it difficult to provide accurate crosswalk instructions.

Allowed Amount:
In the 835 the Allowed amount is sent as informational only in the 2110 when AMT01=B6 (Situational Segment). There is no specific place to cross walk this informational amount in the 837 Professional.
Approved Amount:
In the 835 the Approved amount can be reported in the CAS segment. In the 837 the approved amount goes in the 2430 loop in the AMT02 when AMT01 = AAE as informational only.

Is allowed and approved supposed to be the same thing? If then are, then both pieces of data are situational and informational and the crosswalk is easy. If there is a difference in meaning what does the 835 workgroup recommend?

Response

Within the 835 the total covered amount for the claim is reported in 2100 AMT Segment using qualifier AU and the allowed amount for an individual service is reported in the 2110 AMT segment using qualifier B6. When reporting the allowed/approved amount in the 837, it is reported in the 2430 AMT Segment using qualifier AAE.

Allowed amount and approved amount are synonymous.
Submission 8/2/2005
Status Date 10/3/2005
Status F - Final
Primary References
Document 004010X091A1
SectionDetail
Page158
Set ID835
Table2
Loop2110
Segment Position110
Segment IDAMT
Element Position02
Industry NameService Supplemental Amount