How does the amount reported as PR45 (PR = patient responsibility; 45 = Charges exceeds fee schedule/max allowed or contracted fee arrangement) gets counted in claim line balancing.
Based on the rules, it appears that the Charged amount = allowed + PR45 amount. The allowed amount can then be composed of deductible, coinsurance, and Payment amount.
We get 835 ERAs that report incorrectly allowed amount to be the same as charged amount, then attribute the difference between deductible + coinsurance + payment and the charged amount to PR45, which appears to result in failure of claim balancing.
1.10.1.4 Remittance The 835 must be balanced whenever remittance information is included in an 835 transaction. For a balanced 835, the total payment must agree with the remittance information detailing that payment. The remittance information must also reflect an internal numeric consistency. ASC X12 835 5010x221 TR3 page 12
CPT 81003:
Charged amount $50
Allowed amount $50
Deductible $0
Refer to Section 1.10.2.1.1 Service Line Balancing. The submitted service charge (SVC02) minus the sum of all monetary adjustments (CAS03) must equal the amount paid for this service line (SVC03) and “1.10.2.1.2 Claim Balancing” The submitted claim charge (CLP03) minus the sum of all the monetary adjustments at the claim/line level (CAS) must equal the claim paid amount CLP04.
TR3 Note about the AMT: “This segment is used to convey information only. It is not part of the financial balancing of the 835.”
AMT Claim level qualifier AU “This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered”
AMT qualifier B6, “Allowed amount is the amount the payer deems payable prior to considering patient responsibility.”
The PR 45 is an adjustment based on a contracted rate or legislated fee arrangement. This amount is not included in the AMT*B6 since the payer did not deem it as “payable”. The expectation is the allowed is what the payer would pay up to and the member may be responsible for a portion of that allowable amount. The amount reported with CARC 45, the payer does not deem as payable amount therefore it is not included in the AMT02, where the qualifier is B6, regardless of who is responsible.