RFI Browser

Back  RFI # 539: Obligated to Accept

Formal vs. Informal Help Informal Formal

Submitter

Gigi Mendenhall

Description

When billing to Medicare after Primary payment, is there a place on the 837P to indicate the Obligated to Accept amount? Or, should this amount be derived by Medicare by subtracting the 2430/CAS CO amounts from the 2400/SV1 Billed Amount? Should the 2320 and 2430 Remaining Patient Liability AMT segments be used in calculating the obligated to accept amount?

Submitter Assigned Keywords

OTAF

Response

The 5010 version of the claim implementation guide has an amount segment for Remaining Patient Liability. This amount is submitted when there is a remaining amount to be paid after adjudication by a previous payer. This remaining liability amount must recognize contractual obligations between the provider and the previous payer.
To summarize, the amount reported as the Remaining Patient Liability Amount added to the Prior Payer Paid Amount equals the Obligated to Accept Amount.

In some implementations of the previous version of the claim implementation guide, the CN1 segment was used to indicate the amount that the provider must accept as payment in full. In the 5010 version, there is specific wording in the guide that limits the segment to non-HIPAA claims, therefore it can not be used for secondary claims to indicate the amount that the provider is “obligated to accept.”

Recommendation

The official response to a formal RFI is a letter from the current ASC X12 chair. This website often displays a summary of the RFI. Click here to view a PDF of the letter for this RFI.
Submission 3/28/2007
Status Date 10/10/2007
Status F - Final
Primary References
Document 005010X222
Section3.1.4
Page507
Set IDx222