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Electronic Remittance Informational Notice: Allowed Amounts

November 7, 2016

As of Oct. 24, 2016, the 835 Electronic Remittance Advice (ERA) began displaying incorrect allowed amounts at the service line; however, all payment, patient share (PR), and contractual obligation (CO) amounts are correct at both the claim and service line level detail. Additional information is included below to assist you while Blue Cross and Blue Shield of New Mexico (BCBSNM) works toward resolving this issue. If you use a billing service or other vendor to receive the 835 ERA (HIPAA-standard transaction) on your behalf, please ensure they are aware of this information.

To verify the allowed dollar amount, refer to the 835 ERA claim level segment AMT *AU*, which displays the correct amount. The AMT segment is only used to convey information and is not part of financial balancing of the 835.

Which 835 ERA segment indicates incorrect information?

The AMT*B6* segment should reflect the paid amount, along with the patient’s deductible and/or coinsurance amounts. Currently, this segment is only displaying the paid amount.

Refer to the below 835 ERA example and interpretation when determining the correct allowed amount.

CLP*1262666AF11897*1*414.51*126.96*14.1*12*0201630650E5111X00*22*1~
NM1*QC*1*DOE*JOHN****MI*PTC820229472~
NM1*82*1*JONES*DOCTOR****XX*1923330374~
REF*1L*0001201110004~
REF*CE*PREFERRED PROVIDER ORGANIZATION~
DTM*232*20161028~
DTM*233*20161028~
DTM*050*20161101~
AMT*AU*141.06~
SVC*HC:99219*414.51*126.96**1~
DTM*472*20161028~
CAS*PR*2*14.1~
CAS*CO*45*273.45~
REF*6R*1663368~
AMT*B6*126.96~

Interpretation:

In this example, the AMT*B6* segment amount of 126.96 is equal to the service line payment amount. Segment/data element of CAS*PR*2*14.1, plus the 126.96 paid amount, equals the amount of 141.06 in segment claim level allowed amount AMT*AU*.

BCBSNM is working to expedite resolution of the above issue in a timely manner and apologize for the inconvenience. Future updates and communications will be made available to help keep you informed. If you have questions or need assistance regarding this notification, please contact our Electronic Commerce Center at 800-746-4614.