Could a primary payer require a provider to populate the patient responsibility amount (co-payment, coinsurance, deductable) in 837 I, loop 2300, AMT*F3 and population of the CAS segment in loop 2430 with claim adjustment group code PR in CAS01 and claim, adjustment reason code 1, 2 or 3 when the claim is submitted to the primary payer and there is no coordination of benefits between payers?
Is it allowed the AMT and CAS segments to be used for other purposes than Coordination of Benefits between payers?
Reference: 005010X223
The amount reported in the loop 2300 Patient Estimated Amount Due AMT segment is the provider's estimate of the amount from the submitted charge that the patient is responsible to pay. It is independent of whether the destination payer is primary or not, and whether there is coordination of benefits or not. The amount reported is as determined by the provider, and usage cannot be modified or redefined by a destination payer.
The situational rule for the 2320 loop reads "Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation, do not send."
The rule on the 2320 loop CAS segment reads "Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation, do not send."
The 2320 loop is only present when there is a potential payer besides the destination payer. The CAS segment can only be present when that other payer is a payer that has adjudicated the claim and there is claim adjustment information. If the destination payer and the other payer do not coordinate benefits, these rules still apply to the claim. CAS segment TR3 Note # 4 also identifies that the CAS segment only contains non-zero adjustments.
The presence of specific values in the CAS segment are dictated by the adjudication of the other, adjudicating payer and can't be required by a destination payer.
A destination payer can't require the presence of the AMT or CAS segment in contradiction of these rules.
ASC X12 recommends that providers use the 2300 Patient Estimated Amount Due AMT segment as an informational estimate of the amount that has been determined to be not covered by the payer and therefore due from the patient. ASC X12 further recommends that the amount cannot be validated against other data in the claim and that payers not use the amount in payment calculations.
Prior Related RFI - 1864