Other Payer Patient Responsibility Amount Only Billing

PDX Third Party Exceptions

Other Payer Patient Responsibility Amount Only Billing

For COB processing based on Other Payer Patient Responsibility Amounts, the net amount due is the sum of the payable components of the Other Payer Patient Responsibility values from

  • the LAST payer

  • as determined by 338-5C Other Coverage Type (Primary, Secondary, and so on)

  • that returned a PAID response

When reimbursement is based on the Other Payer Patient Responsibility Amount, EPS returns a Basis of Reimbursement Code (522-FM) of 14.

The payer's response returns these fields (NP = Amount Paid Qualifier, NQ = Amount Paid):

  • NP=01  NQ from 517-FH Amount Applied to Periodic Deductible

  • NP=02  NQ from 134-UK Amount Attributed to Product Selection/Brand Drug

  • NP=03  NQ from 523-FN Amount Attributed to Sales Tax

  • NP=04  NQ from 520-FK Amount Exceeding Periodic Benefit Maximum

  • NP=05  NQ from 518-FI Amount of Copay

  • NP=06  NQ from 505-F5 Patient Pay Amount

  • NP=07  NQ from 572-4U Amount of Coinsurance

  • NP=08  NQ from 135-UM Amount Attributed to Product Selection/Non-Preferred Formulary Selection

  • NP=09  NQ from 129-UD Health Plan Funded Assistance Amount (always negative or zero)

  • NP=10  NQ from 133-UJ Amount Attributed to Provider Network Selection

  • NP=11  NQ from 136-UN Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection

  • NP=12  NQ from 137-UP Amount Attributed to Coverage Gap

  • NP=13  NQ from 571-NZ Amount Attributed to Processor Fee

Note: If NP value 06 (505-F5 Patient Pay Amount) is submitted, EPS does not submit any other qualifiers or values.