AMT

Claim Supplemental Information

Pos: 062	Max: 14
Detail - Optional
Loop: 2100	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

I

Interest

T

Tax

AU

Coverage Amount

Use this monetary amount to report the total covered charges.

D8

Discount Amount

Prompt Pay Discount Amount

DY

Per Day Limit

F5

Patient Amount Paid

Use this monetary amount for the amount the patient has already paid.

NL

Negative Ledger Balance

Used only by Medicare Part A and Medicare Part B.

T2

Total Claim Before Taxes

ZK

Federal Medicare or Medicaid Payment Mandate - Category 1

ZL

Federal Medicare or Medicaid Payment Mandate - Category 2

ZM

Federal Medicare or Medicaid Payment Mandate - Category 3

ZN

Federal Medicare or Medicaid Payment Mandate - Category 4

ZO

Federal Medicare or Medicaid Payment Mandate - Category 5

ZZ

Mutually Defined

NOT ADVISED Use this number for the operational cost or day outlier amount. (Used exclusively by Medicare Part A.)

AMT02

782

Monetary Amount
Description: Monetary amount
Industry: Claim Supplemental Information Amount

M

R

1/18

Required

Notes:

1. Use this segment to convey information only. It is not part of the financial balancing of the 835.
2. Use this segment only when the value of specific amounts identified in the AMT01 qualifier are Non-zero.

Example:

AMT*T*49~