Top Management Story

Writen by Michael Russell

If it seems that the FA0 specifications go on forever, they pretty much do. In this medical billing installment, concentrating on electronic billing of claims using NSF 3.01 specifications, we'll be focusing on FA0 record fields 48 through 55.

FA0 field 48, positions 224 - 230, is the obligated to accept amount. If this sounds like strange English then a little explanation is in order. When billing a medical carrier or payer such as Medicare, most doctors are what are called participating providers. This means they participate in the universal Medicare program. As participating providers, one of the things that they are bound to is the fees set by the Medicare administration for each service provided. By accepting this agreement, when sending a bill to Medicare there is what they call an obligated to accept amount. This means that regardless of what the doctor wants to charge for the service, this is the amount that he agrees to receive from Medicare when payment is made. This is the amount that is transmitted in this field.

FA0 field 49, positions 231 - 237, is the drug discount amount. For claims where there are drugs or medications involved, this is the amount of discount that the patient is entitled to for that particular drug. This field is not used too often but it is available and functional.

FA0 field 50, position 238, is the type of units indicator. This is an indicator that is also seldom used to show how the units are being billed, whether it be box, carton or single unit.

FA0 field 51, positions 239 - 245, is the approved amount. When all is said and done, this is the amount that is approved by the payer, whether it be Medicare, Medicaid, or a private payer. In most cases, this is the amount that will be paid to the provider or the patient.

FA0 field 52, positions 246 - 252, is the paid amount. This is the amount for this claim, if it was billed prior, that was already paid. In most cases, this will be an initial claim and this field will go over with all zeros. It must be filled in and cannot be left blank or the claim will be denied.

FA0 field 53, positions 253 - 259, is the beneficiary liability amount. This is where things get a little hairy. If a claim is not paid in its entirety and there is an amount that needs to be paid by the patient and the patient is no longer living (patients do die during procedures) this is the amount that the patient's beneficiary is responsible for paying. This gets into legal areas that we won't touch here.

FA0 fields 54 and 55, positions 260 - 273, are the balance billing limit charge amount and percentage fields. This also gets into an area that is beyond the scope of this article. Let's just say that it is rare that these fields are used so let's just leave it at that.

In our next installment on medical billing of electronic claims, we'll pick up with FA0 record field number 56.