The situational Rule for the Patient Estimated Amount Due is not very clear (pg 162 from the 837 I TR3). Is the provider required to populate the Patient Responsibility Amount when it is applicable to this claim, but the claim is to be submitted to the Primary Payer and there is no Coordination of Benefits? Please clarify how the provider should indicate if the amount is coinsurance, co-payment or deductable?
Reference: 005010X223
The 2300 loop AMT segment situational rule reads “Required when the Patient Responsibility Amount is applicable to this claim. If not required by the implementation guide, do
not send.” The Appendix E Data Element Dictionary Glossary defines the Implementation Name of “Patient Responsibility Amount” as “The amount determined to be the patient’s responsibility for payment.”
This amount is the provider’s estimate of the amount from the submitted charge that the patient is responsible to pay. It is independent of whether the destination payer is primary or not, and whether there is coordination of benefits or not.
A receiving payer cannot determine coinsurance, copay or deductible amounts from this segment; rather, those adjustment amounts can only be determined from the Other Payer CAS segments within the 2320 and 2430 loops of the claim.
RECOMMENDATION
The Patient Estimated Amount Due was originally intended to be the provider’s estimate of the amount due from the patient, as was documented in Form Locator 55 in the UB-92.
The amount due from the patient was eliminated with the change from UB-92 to UB-04. As documented in the UB-92, this amount was only intended to be requested for claims to commercial payers. It was not required for Medicare, Medicaid, Champus, or Blue Cross plans. However, dropping that amount was inadvertently missed in changes going from the 4010 to the 5010 implementation guide. ASC X12 will consider removing this segment from the next version of the 837I guide.
ASC X12 recommends that providers use this segment as an informational estimate of the amount that has been determined to be not covered by the payer and therefore due from the patient. X12 further recommends that the amount cannot be validated against other data in the claim and that payers not use the amount in payment calculations.
Prior Related RFI - 1865