Obligated to Accept Field (OTAF) - JE Part A
Obligated to Accept Field (OTAF)
This is the amount the provider agreed to accept from the primary payer when the amount is less than the charges but higher than the payment amount; then a Medicare secondary payment is due to the provider.
There is not a specific column or area on an Explanation of Benefit (EOB) that indicates the OTAF amount. However, this amount is determined by other information that is listed on the EOB, such as:
- provider write-off,
- risk amount,
- service benefit credit,
- contractual adjustment,
- provider agreement,
- negotiated savings, or
- an amount that the beneficiary is not liable for.
If the beneficiary were not responsible for any of these amounts, then the OTAF amount would be the same as the amount the primary insurance allowed. Using an OTAF amount will indicate that there is a discount that the beneficiary was not responsible for. This may have to be manually calculated, by taking the billed amount minus the discounts/adjustments to calculate the OTAF.
Example: When the allowed amount is $100, the primary insurance pays $45, the provider OTAF amount is $50, then Medicare would pay $5 as secondary.
Value Code 44 should be used when you are obligated to accept the primary payment as payment in full (OTAF). This is the amount the provider agreed to accept from the primary payer when the amount is less than the charges billed, but higher than the payment amount. In this situation, Medicare secondary payment is due.
The OTAF amount is usually the same amount as the primary allowed amount. A provider may not have an actual contract with the primary insurance, but accepts the primary insurance companies paid amount.
Example: If the provider bills $100 and the primary insurance allows $80 and pays $60.00, the provider's OTAF amount is $80 and Medicare will pay $20 as secondary payer.
Although the beneficiary's primary payer may have paid a claim in full, you are required to submit all inpatient claims and outpatient claims needed to satisfy the Part B deductible; however, in case future changes are required, we recommend that all Part B services are submitted to avoid timely filing issues. The claims should be filed as covered claims, but will be processed without payment.