Thanks!
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
------------------( Forwarded letter 1 follows )--------------------
Date: Wed, 25 Jul 2001 09:43:57 -0400
To: jonathan.showalter
From: [EMAIL PROTECTED]
Subject: Re: Credit Reserve
Jonathan,
My message did not get to the WEDI listserve since I am not a member. I
would appreciate it if you would forward this on to that group as well.
Thanks,
Bob
----- Forwarded by Robert D Poiesz/ISG/CORP/Highmark on 07/25/01 09:42 AM
-----
robert.poiesz@hi
ghmark.com To: [EMAIL PROTECTED]
cc: [EMAIL PROTECTED],
[EMAIL PROTECTED],
07/25/01 09:14 [EMAIL PROTECTED],
[EMAIL PROTECTED]
AM Subject: Re: Credit Reserve
Please respond
to x12n23
Jonathan,
This is a question of perspective.
You are assuming as a starting point that you must tell the provider about
any copay, deductible or coinsurance dollars. Then you are paying those for
the patient from the Credit Reserve account. One of the reasons you are
holding this perspective may be that you are thinking in terms of the
current paper or flat file remittance advices where there are specific
'boxes' for this data. You always show the deductible, etc. From that
perspective this would be an adjustment.
The comments that have come from me and the others in the Claim Payment
Listserve are from a different perspective. The 835 only reports
information that results in a change in payment. If the deductible is
being met through a disbursement from a credit reserve account, then
deductible is NOT reducing the payment on this claim. ( I can get into
other examples and describe similar situations where the work group has
used similar logic, but that is done better by voice.) The patient may
need to see this financial information on the EOB, but not the 835 to the
provider. If the deductible had already been met to a different provider,
there would not be an adjustment for a $0 deductible. The fact that the
patient's responsibility is being met through another means (credit reserve
or even the primary payer's payment for a secondary claim) is not germaine
to the 835.
As has been mentioned previously, if the provider had collected the
deductible erroneously, there is a way in the 835 to show that you are
making a payment for the appropriate refund amount directly to the
responsible party - that is an adjustment that reduces the provider's
payment.
There is a difference between a factor in the adjudication process and
something actually being a change in the payment on the claim/service,
especially where the patient's responsibility is involved. The work group
participants over the years have been VERY sensitive to what information is
appropriate for the provider and what is not. For instance, information
that applies to the claim due to a contract between the provider and payer
would always be reported, such as Outlier amounts on a claim paid by DRG.
Information related to the contract between the payer and the patient that
does not have a direct impact on the provider payment is not something that
the provider needs to know. In this case, the provider may need to know
that a Credit Reserve account can or does apply, but they have no need to
know the dollars involved. They are getting paid.
I understand that you may disagree with this perspective. At this point,
all of the feedback that we have had from the WG listserve is supporting
this perspective.
Bob
JONATHAN.SHOWALTER@
bcbsne.com To:
[EMAIL PROTECTED], [EMAIL PROTECTED]
cc:
[EMAIL PROTECTED], [EMAIL PROTECTED]
07/24/01 05:58 PM Subject: Credit Reserve
I have a basic question.. what is an adjustment? When I researched this
question I came up with the following information. This is how I concluded
that that Credit Reserve was indeed an adjustment. FYI.. "Credit Reserve"
must be expressed at the line level and the claim level. "Credit Reserve"
is
only a factor when paying secondary or tertiary claims.
1. What is an adjustment? This is found on Washington Publishing site
when
you click on the Adjustment Reason Codes and click on List Description
CLAIM ADJUSTMENT REASON CODES
Introduction
Claim adjustment reason codes communicate an adjustment, meaning that they
must communicate why a claim or service line was paid differently than it
was
billed. If there is no adjustment to a claim/line, then there is no
adjustment
reason code. Claim adjustment reason codes are used in these ASC X12N
version
4 release 1 transaction set implementation guides:
*** We are meeting the definition of "...claim or service line was paid
differently than it was billed..."
2. I don't believe that a claim with Credit Reserve will balance.
Page 19 of the 835 states Amount 1 (submitted charge for this service) -
Amount 2 (monetary adjustment amount applied to this service) = Amount 3
(Paid
Amount for this Service). How can I balance this line when the charge
minus
the adjustment will not equal the paid amount..assuming there won't be a
credit reserve amount adjustment code to show the credit reserve amount
applied to the line.
Thanks!
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
------------------( Forwarded letter 1 follows )--------------------
Date: Tue, 24 Jul 2001 07:41:40 -0400
To: JONATHAN.SHOWALTER
Cc: [EMAIL PROTECTED], [EMAIL PROTECTED]
From: [EMAIL PROTECTED]
Subject: Re: New Adj Reason Code
Jonathan,
What we have seen so far is that those responding to your message do not
feel that you need a claim adjustment reason code. This is not an
adjustment to the claim. That tells us how you will not tell the
providers. As to other options, there are three that I can see off the top
of my head.
1 - the providers do not need this information because people are the issue
with your scenario, but the 835 is computer processed and will accept the
payment without question. To do otherwise requires that the vendor program
the computer to compare actual payment with some expected payment and
report both over and under payments to the office staff. Not all systems
will program in the checking, and I would guess that most of those that do
will only report out under payments.
2 - Use the Claim level REF segment to report a Class of Contract Code that
identifies the contract type. You control the coding here and can assign
codes/definitions that identify which types of accounts participate in the
Credit Reserve. Then, providers will not be suprised if they receive a
higher payment than expected on that class of contract. (I think that this
is the approach I would prefer)
3 - Use the MIA or MOA segment to report a Claim Payment Remark Code
identifying that the "Normal Patient Responsibility amount has been
partially or completely paid through a credit reserve account". These
codes are available through Washington Publishing. They are owned by CMS
(HCFA) and you can request a new code online. I would recommend that you
word your code request to be as generic as possible, so that others will be
able to use it as well.
Thanks,
Bob
PS - any on the listserve interested in adding their two cents or
preference, please do so.
JONATHAN.SHOWALTER@
bcbsne.com To:
robert.poiesz@highmark.
com
cc:
07/23/01 05:05 PM Subject: Re: New Adj
Reason
Code
Bob,
I don't think I have clearly communicated the issue clearly. I cut a
single
check to a provider for a claim for $125 dollars (total charges of claim
$125)... They normally would expect to get $75 dollars in this case. I
need
to tell the provider what amount I paid as per our fee schedule and how
much I
paid them as part of Credit Reserve. If I don't tell them why, they don't
know what to do with the extra payment because they are smart enough to
know
and honest enough not to just take the money without asking questions about
how the amount should be applied to the account.
Without this code, how will I tell the provider the reason they received an
extra $50 for this claim?
Thanks!
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
------------------( Forwarded letter 1 follows )--------------------
Date: Mon, 23 Jul 2001 13:38:02 -0400
To: JONATHAN.SHOWALTER
From: [EMAIL PROTECTED]
Subject: Re: New Adj Reason Code
Jonathan,
I messed up and did not include you on the message to the list serve.
Here are the responses I am getting:
We refer to this in our system as "COB Savings". Normally, the provider
bills us for $100 and also reports the $20 co-pay received from the
patient.
Assuming that there are no other adjustments, we would prepare a check to
the provider for $80 and a check for $20 to the insured. The provider has
no need to know about the COB Savings, so we don't inform them of it.
Neil A. Bryson
The Calends Group, Inc.
219-485-0273 x 234
In response to the need of a new adjustment reason code for the 835 to
report this a "payment from credit reserve": I do not believe that this
would be a true adjustment. The calculation in the 835 is the submitted
charges less adjustments equals the payment, and if co-pay is not being
adjusted from the charges, there is no need to report this information.
The
states/providers/payers that fall within the utilization the "credit
reserve" should have knowledge of this activity, realize that it is not
deducted, thus the 835 calculation holds true.
Thank You,
Desiree Van Lieu
FCSO/FISS
[EMAIL PROTECTED]
I will foward others as I get them and send out any response you would like
me to deliver.
Bob
Bob
JONATHAN.SHOWALTER@
bcbsne.com To:
robert.poiesz@highmark.
com
cc:
[EMAIL PROTECTED]
org, [EMAIL PROTECTED]
07/23/01 11:33 AM Subject: Re: New Adj
Reason
Code
The provider needs to know about this amount because it is above the amount
they would normally get paid. For example, service X is submitted for $100
dollars and the fee schedule says pay the provider $80. Without COB/Credit
Reserve Savings, you would show that the patient is responsible for the
other
$20 dollars and that would be the end of the story....but.... in the case
of
COB/Credit Reserve Savings the providers check is written for an extra $20
they want to know why. Our customer service dept is telling me that
providers
ask why they were "overpaid" all the time... at least that is how they look
at
it until they realize we are paying the subscriber liability for the
subscriber.
Thanks!
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
------------------( Forwarded letter 1 follows )--------------------
Date: Mon, 23 Jul 2001 08:42:18 -0400
To: JONATHAN.SHOWALTER, [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
From: [EMAIL PROTECTED]
Subject: Re: New Adj Reason Code
Jim & Jonathan,
The 835 requires adjustments only when there is a change to the amount
being paid.
As I see this situation, the payment from this 'account' would not need to
be reflected in the 835 because this payment would be offsetting patient
responsibility adjustments. What I would recommend is not to report any of
those adjustments.
For instance, if there is a claim for $100 where a 20% copay would apply,
the norm would be to report a CAS*PR*3*20~ adjustment. Because this is now
going to be paid out of this new account, you can eliminate reporting the
copay to the provider. The alternative would be reporting offsetting
adjustments with some new (call it XX) adjustment code as
CAS*PR*3*20**XX*-20~, and I don't think that this level of information is
needed.
My assumption in this is that the provider does not have a need to know
where the payment comes from, just that the payment is being made.
Obviously, the patient DOES care about this, but the patient never gets an
835.
Bob
PS - I am copying the Claim Payment Listserve to get other comments if
someone disagrees with this analysis.
"Jim Whicker"
<ARJWHICK@ihc To:
<[EMAIL PROTECTED]
m>, <[EMAIL PROTECTED]>
.com> cc:
Subject: Re: New Adj Reason
Code
07/23/01
08:13 AM
Bob - Jonathan posted this to the WEDI listserve ... was wondering if the
835 committee had ever discussed this topic and had suggestions??
Jim
>>> [EMAIL PROTECTED] 07/20/01 11:04AM >>>
Some of you may be aware that a handful of states (Nebraska being one) have
adopted the concept of "Credit Reserve/COB Banking". This allows a member
to
accumulate money saved from COB into an account. Money is then paid to the
provider/member from this account when charges are the subscribers
liability.
At issue is the fact that no HIPAA Adjustment Reason Code exist to express
this to the provider. Has anyone on the list developed the text for such a
code. I would like to formulate a request for a new claim adjustment
reason
code but one that everyone could use for this reason.
Perhaps something as simple as "Payment from Credit Reserve"?
Have any of you thought about how to express this if it applies to you? I
have not found an adjustment reason code to do this.. have any of you? If
it
is true that a no
current adjustment reason code exist today, what do you think about the
suggested text of the message above? Is it clear to providers and payers?
Thanks!
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
**********************************************************************
To be removed from this list, send a message to:
[EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
**********************************************************************
To be removed from this list, send a message to: [EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
