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Back  RFI # 360: Allowed/Covered Amount

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Submitter

Doreen Espinoza

Description

In our efforts to create a COB cross walk from the 835 to the 837 we found that there are terminology that can be very confusing and hinder the crosswalk effort. We would like the 835 workgroup to either affirm our definition or provide a definition for the following terms.

Allowed Amount is the billed charge minus Contractual Discounts
Covered Amount is the Allowed Amount minus the Non Covered Charges

Response

The meaning of covered, allowed, and approved can be confusing since a standard definition does not exist within the industry. Through discussions we have found that allowed amount, covered amount, and approved amount are used synonymously. Therefore, how a business decides to define these terms is that entities decision.

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.
Submission 11/15/2005
Status Date 1/11/2006
Status F - Final
Primary References
Document 004010X091A
SectionDetail
Page135
Set ID835
Table2
Loop2100
Segment Position062
Segment IDAMT
Element PositionID
Component Position01
Industry NameClaim Supplemental Information
External Code List522