In a non-participating provider situation, and when a member is responsible for the entire billed amount, how should the payer determine the allowed amount that is reflected in the AMT02 of the AMT*B6 segment of the 5010 835, particularly if a fee schedule is used to pre-price the claim?

The 5010 835 TR3, 2110 AMT B6 code note says, “Allowed amount is the amount the payer deems payable prior to considering patient responsibility.” If the payer deems that the entire billed charges are payable by the member because the provider is non-participating, is the allowed amount the same as the billed charges?  Or is it up to each payer’s understanding of how the allowed amount should be calculated, or is an allowed amount not applicable when the member is responsible for the entire billed amount for a non-participating provider situation?

The 837 TR3s, section 1.4.5, provides information on how to calculate the Allowed/Approved Amount in an 837 COB situation, and indicates these amounts vary in definition depending on perspective.  For a payer, the allowed amount is calculated by adding the prior payer payment plus the sum of all patient responsibility adjustments that are identified with a group code of PR.  Is it a similar calculation for the 835 allowed amount when a non-participating provider situation exists, where the allowed amount considers the sum of all patient responsibility amounts?