Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Required Other Amount paid by Payer paid 0 towards this claim line, else when Insurance PC 68 11/8/12 Integer Currency a Primary / Prior do not report any value here. Do not PC025 = 98% A2 Paid Carrier code decimal or round up / down to whole 02, 03, 20, Amount dollars code zero cents (00) when or 21 applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount Medicare paid towards this line. Only report 0 here if Medicare paid 0. If Medicare did not pay Medicare Amount towards this claim line do not report any Required PC 69 Paid 11/8/12 Integer Currency Medicare paid value here. Do not code decimal or round when 98% A1 Amount on up / down to whole dollars code zero PC112 = 1 cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by Required provider contract and most often it is less when Allowed PC 70 11/8/12 Integer Currency Allowed Amount than or equal to the fee charged by the does not = 99% A2 amount pharmacy Do not code decimal or round 4, 22, or up / down to whole dollars code zero 23 cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the amount that the patient has paid beyond the structure. Report 0 if Amount patient has not paid towards this claim Member member/patient line. Do not code decimal or round up / PC 71 Self Pay 6/24/10 Integer Currency paid out of All 20% B down to whole dollars code zero cents Amount pocket on the (00) when applicable. EXAMPLE: claim line 150.00 is reported as 15000; 150.70 is reported as 15070
PC 68 Other Insurance Paid Amount 11/8/12 Integer Currency Amount paid by a Primary / Prior Carrier Report the amount that a prior payer has paid for this claim line. Indicates the submitting Payer is 'secondary' to the prior payer. Only report 0 if the Prior Payer paid 0 towards this claim line, else do not report any value here. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC025 = 02, 03, 20, or 21 98% A2 PC 69 Medicare Paid Amount 11/8/12 Integer Currency Amount Medicare paid on Report the amount Medicare paid towards this line. Only report 0 here if Medicare paid 0. If Medicare did not pay towards this claim line do not report any value here. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when PC112 = 1 98% A1 PC 70 Allowed amount 11/8/12 Integer Currency Allowed Amount Report the maximum amount contractually allowed, and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the pharmacy Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Required when does not = 4, 22, or 23 99% A2 PC 71 Member Self Pay Amount 6/24/10 Integer Currency Amount member/patient paid out of pocket on the claim line Report the amount that the patient has paid beyond the structure. Report 0 if patient has not paid towards this claim line. Do not code decimal or round up / down to whole dollars code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 20% B