Section title: Requests for Interpretation
Methodology for calculating qualifying payment amount (835)

Hi, this is in addition to previous asked question on HR133 No Surprise billing. I was shared by CAQH group that there is no mention of electronic, 835 mention that a billing provider needs to provide the qualifying payment. However, per the internal business partner. They found the following rule indicating electronic form to be shared by the non-participating provide to the provider or facility. Could you please elaborate whether it is required or not?


§ 149.140 Methodology for calculating qualifying payment amount.

(d) Information to be shared about qualifying payment amount. In cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services is the qualifying payment amount, the plan or issuer must provide in writing, in paper or electronic form, to the provider or facility, as applicable.

(1) With each initial payment or notice of denial of payment under § 149.110, § 149.120, or § 149.130.

(ii) If the qualifying payment amount is based on a down coded service code or modifier-

(A) A statement that the service code or modifier billed by the provider, facility, or provider of air ambulance services was down coded.

(B) An explanation of why the claim was down coded, which must include a description of which service codes were altered, if any, and a description of which modifiers were altered, added, or removed, if any; and

(C) The amount that would have been the qualifying payment amount had the service code or modifier not been down coded.

RFI Response

The current 5010 835 TR3 does not support reporting the qualified payment amount in the 835.

It is not within X12’s purview to comment on policies, procedures, or regulations generated by an entity outside of X12.

RFI Recommendation

If this is functionality that is needed for your business and not currently supported in a published TR3, please submit an X12 maintenance request at