General Billing Question - Newbie

[rumpa_g]

Hello,

I am trying to find out if these are actual scenarios encountered by a biller and how do they accomodate the exception to the rule?

Case 1 - Claim Charge = $50

CPT Code	Charges
99213	25
99214	25

ERA Came back - Paid Amout = 25

CPT Code	Charges	Ins Paid	Ins Adj.	Pat Resp
99213	25	20	0	5
99214	25	5	20	0

I realize that the 99214 I should have been paid 20 instead of 5, what do you do? Do you submit another claim with 99214 as the only service line and charge the rest of the amount (25 - 5)[Charge Amount - Ins Paid] or you charge again 25? How do you indicate that in your judgement the line item was partially paid?


Case II -

For Secondary Claims - how do you determine the final patient responsibility - in the software you use - does it reflect the patient balance properly?

For example -
Claim - Total Charge = 50 Aetna paid = 40, declares patient responsibility = 10.
You submit the claim to the secondary ins. CIGNA and CIGNA pays $5 and puts remaining to patient responsibility of 5, as a result the patient now owes 5. But does your software reflect that properly?

Thanks,
Rumpa

[Michele]

For case I, I'm confused as to if both 99213 & 99214 were billed with the same date of service, and why are they both $25?

Anyway, it is hard to answer the question without knowing if they were for different dates.  If they were for the same date, both would not be allowed. 

But if you feel that a charge was not paid appropriately then you need to appeal it either by a phone call or in writing.  Just explain why you feel it wasn't paid correctly.

For Case II, the patient responsibility would be $5 and if it is entered correctly your software should reflect that. 

Amt Billed  -  $50
Prime Pd   -    40
2ndary pd -     5
Balance          5   -  Pt responsibility.

Michele