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Back  RFI # 888: 2110 B6 Amount Allowed Actual

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

The 5010 guide shows B6 Allowed Actual "The amount the payer deems payable prior to the pt responsibility". Can I please get clarification on the B6 AMT segment? Is B6 the contract amount? Should the contract amount include the payers contractual adjustment?

Example 1
Allow Amt = Pmt Amt + Coins + Ded + Copay + contractual Adjustment

$500 Total Charges
25 Non Cov Personal items
$475 Allowed /Actual (includes $100 pmt +$75 ded + $300 contractual adj)

Example 2
$500 Total charges
25 Non Covered items
$100 Non covered service line
$200 Contractual adj
$175 Allowed Amt = ($100 pmt + $75 ded,coins,copay)

Submitter Assigned Keywords

B6 Amt Allowed/Actual

Response

This issue is explicitly addressed in guide 005010X221. The note on the 2110 Loop AMT segment AMT01 qualifier B6 reads "Allowed amount is the amount the payer deems payable prior to considering patient responsibility." This note excludes from the allowed amount any part of the service charge that is not deemed payable by the health plan. Since a contractual adjustment is not payable, those adjustments are not included.

In other words, the allowed amount for a provider under contract will be the health plan's fee schedule amount for that specific procedure. For example, if the submitted charge is $500, and there is a $200 CO*45 adjustment, then the Allowed Amount is $300, independent of how much deductible, co-pay or co-insurance may then be applied to that service line.
Submission 10/12/2009
Status Date 11/11/2009
Status F - Final
Primary References
Document 005010X221
SectionClm Pmt
Page211
Set IDAMT02
Table2
Loop2110
Segment PositionAMT02
Segment IDAMT