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Copays over contracted allowances

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DMK:
From your lips to God's ears!

PMRNC:

--- Quote ---From your lips to God's ears!
--- End quote ---

I'm not even religious but I am singing.. AMEN!

dmaney:
I thought that the co-pay is the contractually allocated amount that the participant pays for the visit... and that the reimbursement takes into account the already-paid co-pay.  For example, the co-pay is $30.  BC/BS  says that the allowable reimbursement for the visit is $20 (which is not paid because the deductible has not been met).  I didn't think you were supposed to take the $20 from the already- paid $30; the $20 is the amount due over and above the $30.  So the chiropractor is reimbursed $50 total.

DMK:
If the allowed amount is less than the policy's co-pay per visit you can only make the patient pay the ALLOWED amount, they are not responsible for any more than that (if you're a contracted provider).

Example: Blue Cross allows $22.41 for a 98940, the patient's co-pay on their policy is $25.00.  The EOB will show that the patient is only responsible for $22.41.   If they had a 98940 ($22.41) and a therapy ($9.17), the total allowed will be $31.58, the patient is responsible for their total $25.00 co-pay, insurance will pay the remaining $6.58. 

Regardless of WHAT their co-pay is on their policy, if the allowed amount is less, they are only responsible for the lesser amount.

If deductible is in place, the co-pay won't even kick in until the deductible is met.  They will owe for the total allowed amount for the visit .

Michele:
DMK described it perfectly.  The allowed amount INCLUDES the copay, and if the allowed amount is LESS THAN the copay they only owe the allowed amount.  It is not the allowed amount PLUS a copay.

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