I need some clarification on the situational fields in loop 2320 specifically around the the new AMT fields (Remaining Patient Liability and Total Non-Covered Amounts). The usage say they are situational but the situational rules are what get me. Is it saying that if the data has been provided in the 835, then you may provide this information but you won't get a denial if you fail to send it OR if the claim has been adjudicated (has a CAS segment), then these segments are mandatory?
The remaining patient liability amount is required when the other payer has reported only claim level adjudication information (either paper or electronic) and in the judgment of the provider this is the remaining amount to be paid after adjudication from the other payer; this amount is only used in provider to payer COB situations.
The total non-covered amount segment is required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. It is used when the prior payer is not billed because the destination payer’s policy allows providers to submit the claim without the prior payer’s adjudication information. This only applies when there is no 835 or paper remittance from the prior payer.