Medicare EOB - PR - 3 Co-payment Amount

PR - 3 Co-payment Amount


Description:
Copayment A specified dollar amount or percentage of the charge identified that is paid by a beneficiary at the time of service to a health care plan, physician, hospital, or other provider of care for covered service provided to the beneficiary.

Cost Sharing The general set of financial arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for heath care insurance.





Action:

1. We need to bill the patient.
2. If there is any other insurance coverage if the patient has, we can bill to that insurance also.

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Adjustment code - CO and CR - What does it mean

Adjustment Group Code Glossary for "CR" 

CR - - Correction to or Reversal of a Prior Decision

A CR group code is used whenever there is a change to a previously adjudicated claim. CR explains the reason for the correction; PR, CO and/or OA must always be used in tandem with CR to show the revised information. Separate reason code entries must be used in the NSF for the CR group entry, and any other groups that apply to the readjudicated claim.

What is explanation for denial adjustment group code of CO


CO - Contractual Obligations


A CO group code identifies amounts for which the provider is financially liable. These include, participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, Gramm-Rudman reductions, or medical necessity denials/reductions. The patient may not be billed for these amounts.

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Claim processed as PR - 2 Coinsurance Amount

PR -  2  Coinsurance Amount

Coinsurance amounts are generally 20% of the Medicare fee schedule. Physicians must collect the unmet coinsurance from the beneficiary. Consistently waiving the coinsurance may be interpreted as program abuse. If a beneficiary is unable to pay the coinsurance, the physician should ask him or herto sign a waiver that explains the financial hardship. If no waiver is signed, the beneficiary ’ s medical record should reflect normal and reasonable attempts to collect, before the charge is written off.

Action :  

1. We need to file the claim to secondary insurance
2. If there is no secondary insurance we can bill the patient.

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what is ANSI Group Codes

ANSI Group Codes


An ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.

CO -  Contractual Obligations
PR -   Patient Responsibility
OA -  Other Adjustment
CR -   Correction to or Reversal of a Prior Decision
PI - Provider initiated refund

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Insurance claim processed as PR - 1 Deductible Amount

PR - 1 Deductible Amount



Descripition:

In insurance policy terms, a deductible is the amount of money which the insured party must pay before the insurance company's own coverage plan begins. In practical terms, insurance companies include a deductible in their policies to avoid paying out benefits on relatively small claims.


Action : 

1. We need to bill the patient.
2.  If the patient has another insurance coverage which covers deductible we can file to that insurance, if the policy not cover primary deductibles we have no other way rather than billing the patient.

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What is PR and OA - denial EOB

What is explanation for denial adjustment group code "PR"  


PR - Patient Responsibility

A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (reason code B4), excess charges on an assigned claim (reason code 42), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

Adjustment Group Code Glossary "OA"

OA -  Other Adjustment 

An OA group code is used when neither PR nor CO applies. At least one PR, CO or OA group code appears on each remittance advice. For example, OA would be used when a claim is paid in full at initial adjudication with reason code 93 and a zero amount, or with reason codes such as 69-85 that are components of payments rather than adjustments to payments. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.

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What is clean claim

A “clean” claim is defined as a one that does not require the payer to investigate or develop on a prepayment basis. Clean claims must be filed in the timely filing period.

Most payers consider clean claims as:

◆ Claims that pass all edits

◆ Claims that do not require external development (i.e., are investigated within the claims, medical review, or payment office even if the investigator does not need to contact the provider, the beneficiary, or other outside source)

◆ Claims not approved for payment by the common working file (CWF) within seven days of the original claim submittal for reasons beyond the carrier’s or provider’s control (e.g., CWF system/communication difficulties) (Medicare only)

◆ Claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides (CWF out-of-service area [OSA] claims) (Medicare only)

◆ Claims subject to medical review but complete medical evidence is attached by the provider

◆ Additional requests for information is developed on a post payment basis

◆ Have all basic information necessary to adjudicate the claim, and all required

supporting documentation is attached

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Type of denial - difference between rejection and denial

Claim denial types

There is no particular type in denial however below are the common reason
Claim might be denied for incorrect coding information.
Claim might be denied for incorrect provider information.
Claim might be denied for incorrect coverage information
Claim might be denied for lack of information



Claim denials by managed care organization plague long-term care providers 
Should be file the claim to patient HMO plan

Claim denied for coordination of benefits 
Patient needs to update the COB information to insurance. If patient has more than one insurance, patient need to call the insurance and inform that which insurance is primary and secondary for patient. Patient only can update the COB information to insurance.

Claim denied for maximum benefits reached 
File the claim to secondary along with denied EOB. If patient do not have another insurance we can bill the patient.

Claim denied for valid referral 
Should be file the claim with valid referral. If we do not have valid referral number, we can request the same from referring doctor and refile the claim with valid referral.

 Claim denied no billing code.
Kindly call the insurance and get the reason behind the denials and get the correct CPT

Denied benefits is not covered by the patient's plan.
 We can bill the patient.


Denied insurance claims due to invalid cpt code 
     Should be file the claim with valid CPT. For example medicare and HMO plans (Humana, freedom health, AVMED, universal, wellcare, Polk county, PUP,) does not cover the consultation code (99241 to 99245 and 99251 to 99255).

Claim denied reason dates of service over one year from process date are not payable. 
    Should be file the claim with in timely filing limit. If you received the denial even filed the claim with in TFL we can appeal the claim with TFL proof. All insurances has separate filing limit.

 Claim denial codes and what action needs to be taken 
Each denied claim should have valid reason behind the claim denial and needs to take appropriate action from the denials

 Claim denial vs claim rejection 
Claim denied by insurance and claim rejected by clearing house OR EDI department

Claim denials bundling inclusive 
Needs to differentiate the service by using appropriate modifier and Dx else taken write-off the claim balance

Claim denied primary paid in full 
Need to write-off the claim balance.

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Reimbursement rule and reimbursement contract and paying procedures

Understand Reimbursement Rules and Win the Game 

Each health care stakeholder seeks its best service, cost, and outcome solution on a resource scarce playing field. Accordingly, health care's critical role in our modern and aging society has led to the development and constant updating of a huge body of both legislated and interpreted rules. Clearly, each group should start protecting its long-term interests by actively engaging in understanding, implementing, and contributing to the development of these rules. For providers to ensure that they collect what they expect, they need a thorough understanding of reimbursement contracts, payer procedures, and claims denials, and an active management approach to comparing predicted revenue collection to actual collection. 

In order to predict revenue collection, providers must establish necessary expertise in each of the following areas: 

Reimbursement Contract — Providers have to understand how each reimbursement contract handles varied billing requirements, coverage limitations, facility-specific needs, start and end dates, co-pays, per diem rates, and G/L posting references. 

Payer Procedures — Providers have to be intimately familiar with payer procedures. They need to require payers to provide in-service training to provider staff to ensure that they thoroughly understand the payer's procedures. They should insist on receiving initial in-service training for all staff and regular refresher training to bring new staff up to speed on updates and procedure changes. Payer educational materials should be saved for reference. Providers should also develop and systematically maintain a library of provider manuals. Provider staff should be provided with all the tools and information they need to work under the payer procedures, including all payer addresses and phone numbers required for notifications, authorizations, claims, and collection follow-up. 

Claim Denials — Philosophy and technology should be combined to manage claim denials and achieve predicted revenue collection. Understanding and documenting reimbursement contracts and payer procedures is largely dependent on providers negotiating effective contracts and training their personnel on how to follow the rules. The range of reimbursement and compliance rules is great, but there is no substitute for understanding. 

Reimbursement claim denials are variances to the patient encounter revenue-collection plan. In order to reduce these variances, providers need to follow an active and systematic approach: analyzing and prioritizing denial causes; establishing a plan; assigning responsibility; tracking appeal processes according to contracts and payer procedures; and introducing business rules that identify and correct processing problems upstream in patient encounters, thereby preventing denials in the first place. 
The potential to use technology is greatest in the area of claim denial management. When providers add automated and collaborative goal setting, business planning, and accountability to the passive measurement of revenue collection, they create forward-looking and inherently active management that increases revenue predictability.

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Why Don't Providers Collect What They Expect? - In reality

Why Don't Providers Collect What They Expect?

Health care's patient, provider, and payer structure makes accurately predicting revenue collection a particularly difficult challenge. While all three stakeholder groups may be well intended, they simply do not value health care services similarly because of the differences in their individual needs, wants, and approaches to risk management.


Governance of this marketplace is achieved through a large volume of legislated regulations and procedures, and many providers surprisingly jeopardize revenue collection by not understanding the full range of reimbursement rules. Current budget and demographic trends will only increase pressure on the entire health care delivery system into the foreseeable future.

Revenue predictability requires that individual lines of business and their unique revenue streams be understood and managed. Providers should fully recognize patient encounters as the "activities" that drive internal service, cost, and outcome processes. Predicting and actively managing what should be collected for individual encounters should take place before claim denials occur, not after.

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