Difference Between Line Payment Amounts in Carrier File

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