OTAF Amount
Billed Amount
Primary Paid Amount
If Non-Assigned Claim, Check Below
If Non-Assigned, Enter Limiting Charge
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Result
Perform Calculation #1
Psych Services
Services That Pay 100%
All Other Services
Medicare Allowed Amount
Deductible Applied
Perform Selected Calculation #2
Primary Allowed Amount
Perform Calculation #3
The Lowest Amounting Resulting From Calculation #1, #2, Or #3 Is Medicare's Secondary Liability: $
