Section title: Requests for Interpretation
Patient Responsibility

Sometimes, in the opinion of the provider, health plans report information in the 835 inaccurately. When this happens, the Patient Responsibility amount from the 835 may not represent what the provider is really able to collect from the patient. When this happens, is it appropriate for the provider to include amounts identified in the 835 with Adjustment Group codes PI and sometimes OA as Remaining Patient Liability in the 837 secondary claim?

For instance, for a provider out of network with the primary health plan, if a primary health plan reports CAS segment for the amount that exceeds fee schedule as OA*45*300, and the deductible as PR*1*200, is the appropriate secondary 837 entry AMT*EAF*500~?

RFI Response

Yes, if in the judgment of the provider, the adjusted amounts may be adjudicated by the other payer, it may be sent in the AMT02 of the AMT – Remaining Patient Liability segment. The example correctly reflects the AMT02 amount in the case represented.