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Back  RFI # 1028: 835 Clm Processing for CCF acc

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

Scenario: The ERA for the CCF account has a partial payment.
For example:
$500 billed
Medical ERA
$300 deductible from the Medical ERA (PR1)
$200 write off (CO45)
CCF ERA
$125 paid from the patients CCF account (OA187)
$125 previous medical processing (OA23)
$175 remaining amount owed by patient (PR96)
Today on the 835, we identify the remaining patient responsibility as PR96, patient responsibility, not covered.
• Does the provider have any suggestions on codes to use in place of PR96 to better communicate that the remaining amount is the responsibility of the patient?
• One suggestion we received is to use PR1 (deductible) or PR2 (coinsurance), as was indicated on the original medical ERA.
-Does the provider agree this code would communicate the message clearly?
-Would it cause any confusion to receive this code on both the medical and the CCF ERAs?

Submitter Assigned Keywords

HSA HRA FSA 835 processing

Response

The information supplied does not accurately support the COB method of handling a high deductible health plan processing.

Recommendation

The OA 23 amount should be represented as $200.00 as that is the write off amount (if there was a paid amount that would also be included in this OA 23 amount).

There is then $300.00 left of which the $125.00 amount is being paid out of the CCF account then there is a remainder of $175.00 that the patient owes the provider and that amount in both the initial remit from the plan should be reflected as PR – Patient Responsibility 1 – Deductible.

CLP04 = 125

CAS*OA*23*200~

CAS*PR*1*175~
Submission 4/21/2010
Status Date 8/12/2010
Status F - Final
Primary References
Document 005010X221
SectionDetail
Page129
Set IDcas
Table2
Loop2100
Segment Positioncas02