We need clarification regarding if a payer can require 0.00 in AMT02 of the AMT – Remaining Patient Liability segment for COB2 claims
Health Safety Net (HSN) 5010 Companion Guide is requiring 2320 AMT*EAF*0.00 if the prior payer did not process a patient liability or if the claim was denied and there is no patient liability. This amount is already indicated in 2320 AMT*D Prior Payment segment.
Our understanding, based on the Situational definitions in the TR3, this segment is only required:
1. When the Other Payer has adjudicated the claim and provided claim level information only
2. The provider received a paper remittance advice and the provider does not have the ability to report line item information
3. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer
Regardless of adjudication method, our COB2 claim may be created with 2430 SVD segment with what was adjudicated.
Is this payer permitted to make this requirement?
The 005010222A1 guide specifies that the Remaining Patient Liability amount is sent at the line level(2430 AMT segment). The guide allows the amount to be sent at the claim level (2320 AMT segment) when the provider's system does not have the ability to send the amount at the line level or if the Other Payer only provided claim level information. The guide specifically states that a Remaining Patient Liability is not sent in both the line and claim segments. A companion guide requirement that this AMT segment be sent when the listed conditions do not apply contradicts the guide instructions.