Difference Between Line Payment Amounts in Carrier File

Difference Between Line Payment Amounts in Carrier File

Current Version Date: 
06/07/2013

The carrier claims data will contain two payment amount fields at the line item level that appear to be very similar. These variables are the "Line NCH Payment Amount" (LINEPMT) and the "Line Provider Payment Amount" (LPRVPMT). The LINEPMT field is the amount that Medicare is responsible for reimbursing for the line item. The LPRVPMT is the amount that the fiscal entity that processes the claim (i.e. the carrier/MAC) actually paid to the provider. Most providers will bill Medicare directly, so these two amounts will usually be the same. However, some providers will have a beneficiary pay them directly rather than the provider billing Medicare for payment.  Medicare will reimburse the beneficiary for this payment later.

Below are two examples that illustrate the difference. The first example is a scenario where the beneficiary paid the provider directly. The second example is a scenario where payment was sent directly to the provider by the Medicare carrier/MAC.

Example 1 – Payment Made by the Beneficiary  

LINEPMT (Line NCH Payment Amount) = 250.00

LPRVPMNT (Line Provider Payment Amount) = 0.00

LBENPMT (Line Beneficiary Payment Amount) = 250.00

Example 2 – Payment Made Directly by Medicare

LINEPMT (Line NCH Payment Amount) = 250.00

LPRVPMNT (Line Provider Payment Amount) = 250.00

LBENPMT (Line Beneficiary Payment Amount) = 0.00

Article Number: 
167
Author(s): 
This work was performed under CMS Contract Number HHSM-500-2005-00027I.

Disclaimer

The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.