Section title: Requests for Interpretation
RFI #
2662
Repriced Allowed Amount (837 PACDR)
Description

The Post-Adjudicated Claims Data Reporting TR3s for Professional and Institutional (005010X298 and 005010X299) contain HCP - CLAIM PRICING/REPRICING INFORMATION segments. However, Dental 00510X300 does not. Where is Repriced Allowed Amount reported in the PACDR Dental transaction? Would it be the same as CN102 Contract Amount?

Scenario

Medicaid States are required to collect Allowed Amount from Managed Care Plans for CMS T-MSIS requirements: https://www.medicaid.gov

RFI Response

The HCP segments in the Post-Adjudicated Claims Data Reporting TR3s are for the reporting of data received from claims repricers. The intent of this segment is not for submitting data other than from claims repricers.

RFI Recommendation

If this is functionality that is needed for your business and not currently supported in a published TR3, submit an X12 maintenance request at https://x12.org/resources/forms/maintenance-requests.

DOCUMENT ID
005010X300