AMT

Claim Submitted Charges

Pos: 110	Max: 1
Detail - Optional
Loop: 2200D	Elements: 2

Ref

Id

Element Name

Req

Type

Min/Max

Usage

AMT01

522

Amount Qualifier Code
Description: Code to qualify amount

M

ID

1/3

Required

Code

Name

T3

Total Submitted Charges

Found on UB92 - Revenue Code 0001 and also in record 90 Found on UB92 Paper form - Revenue Code 0001 Found on 837 CLM02 (Professional); Revenue Code 0001 (Institutional) Found on NSF - XA0 Record field 12 Found on HCFA 1500 - Block 28

AMT02

782

Monetary Amount
Description: Monetary amount
Industry: Total Claim Charge Amount

M

R

1/18

Required

Notes:

1. Required when the subscriber is the patient.
2. Not all payer’s systems retain the original submitted charges. This may be a result of bundling/unbundling situations. This amount can be used as a secondary match criteria within the payer’s system if the claim has not been changed.

Example:

AMT*T3*75~