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