Please provide clarification for the segment: Remaining Patient Liability Loop 2320 AMT*EAF and Loop 2430 AMT*EAF
Scenario 1) A provider receives a paper remittance that does not clearly identify what claim adjustment reason code to use to correctly report the Patient Responsibility CAS segment. The provider is interpreting the segment situational rule to imply that it would be acceptable to send only the Remaining Patient Liability and no CAS segment when the patient responsibility reason is not clear rather than guessing.
How should the provider construct the secondary claim and populate the CAS*PR adj code is unknown?
Scenario 2) A provider submits a secondary balanced claim according to the front matter instructions and includes the Remaining Patient Liability segment AMT*EAF at the claim level only.
Would it be inappropriate for a payer / intermediary to reject this claim because the AMT*EAF segment is present?
This is explicitly addressed in the professional 837 version 005010X222A1. The Remaining Patient Liability in Loop ID-2320 is reported when the other payer in Loop ID-2330B of this iteration of Loop ID-2320 has adjudicated the claim and has reported claim level information only. OR when the other payer in Loop ID-2330B has adjudicated the claim and the provider received a paper remit and the provider does not have the ability to report line level payment information.
The Remaining Patient Liability in Loop ID-2430 is reported when the other payer identified in the SVD01 of of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information.
In response to the question for scenario 1, if the provider cannot determine the appropriate Claim Adjustment Reason Code to report for the patient responsibility amount, code 192 should be used which is specifically addressed in Front Matter Section 1.4.1.3.
In response to the question for scenario 2, X12 cannot comment on the appropriateness of rejecting a claim. If the conditions of the situational rule exist, then the segment must be sent to be consistent with the TR3.