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Monday, June 28, 2010

Denial EOB - PR and OA adjustment codes

What is explanation for denial adjustment group code "PR"  


PR - Patient Responsibility

A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (reason code B4), excess charges on an assigned claim (reason code 42), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

Adjustment Group Code Glossary "OA"

OA -  Other Adjustment

An OA group code is used when neither PR nor CO applies. At least one PR, CO or OA group code appears on each remittance advice. For example, OA would be used when a claim is paid in full at initial adjudication with reason code 93 and a zero amount, or with reason codes such as 69-85 that are components of payments rather than adjustments to payments. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.


Below is a description of your Explanation of Benefits (EOB). The numbers correspond with the numbers on the sample copy of the EOB (see the last page for an example of an EOB).

1. Claim Processing Office: this is the location of the claims processing office. You can write to customer service at this location.

2. Address: the name and address where the EOB is being mailed.

3. Customer Service: number to call with questions regarding your claim.

4. Group Name: the name of your Group (in most cases, this is your employer).

5. Group Number: the identification number for your Group. Please refer to this number if you call or write about your claim.

6. Location Number: the number assigned to your location within the Group.

7. Location Name: the name or description of the location.

8. Enrollee: the name of the covered employee.

9. Enrollee ID: employee’s social security number (last 4 digits only) or identification number. Refer to this ID number if you call or write about your claim.

10. Plan Number: the identification number for your plan of benefits.

11. Paid Date: if a check was issued, the date it was issued.

12. Fraud Statement: if the services shown are incorrect, contact HealthSmart immediately.

13. Claim Number: the unique identification number assigned to this claim. Please refer to this number if you call or write about this claim.

14. Patient: the name of the individual for whom services were rendered or supplies were furnished.

15. Patient Acct: number assigned by the service provider.

16. Provider: the name of the person or organization who rendered the service or provided the medical supplies.

17. Dates of Service: the date(s) on which services were rendered.

18. Procedure Code: the Current Procedural Terminology (CPT) codes listed on the provider’s bill.

19. Amount Billed: the charge for each service.

20. Charges Not Covered: charge that is not eligible for benefits under the plan.

21. Remark Code: code relating to the “Charges Not Covered” amount. Also used to request additional information or provide further explanations of the claim payment.

22. Discount Amount: identifies the savings received from a Preferred Provider Organization (PPO), if applicable.

23. Discount Code: the corresponding code for negotiated savings.

24. Allowed Amount: maximum allowed charge as determined by your benefit plan after subtracting Charges Not Covered and the Provider Discount from the Amount Billed.

25. Deductible Amount: the amount of allowed charges that apply to your plan deductible that must be paid before benefits are payable.

26. Copay: the amount of allowed charges, specified by your plan, that you must pay before benefits are paid.

27. Covered Amount: eligible charges considered under your plan.

28. Paid At: the percentage of the Covered Amount that will be considered under your benefit plan.

29. Payment Amount: benefits payable for services provided.

30. Column Totals: the sum of each column.

31. Patient Responsibility: after all benefits have been calculated, this is the amount of the enrollee’s responsibility for this claim.

32. Other Credits or Adjustments: represents adjustments based upon the benefits of other health plans or insurance carriers, including Medicare.

33. Total Payment: the sum of the “Payment Amount” column.

34. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section.

35. Paid To: individual or organization to whom benefits are paid.

36. Check Number: the unique number assigned to the check.

37. Check Amount: total benefit amount paid on this claim.

38. Plan Status: deductible/out of pocket status for the current year.

39. Foreign Language Assistance: multilingual contact information will only appear when applicable.

40. Going Green: HealthSmart offers members the option to receive electronic, paperless Explanation of Benefit (EOB) notifications.

41. Important Information: statement explaining your entitlement to a review of the benefit determination on the Explanation of Benefits (EOB). This information varies according to each plan.



What is an Explanation of Benefits (EOB)?


An EOB is a summary page showing how much money your insurance plan paid and how much money you must pay (if any) for a health service you got, like a doctor visit or lab test. Every time you get a health service, you’ll get an EOB from your insurance company in the mail or by email. An EOB is not a bill.

What should I do with my EOB?

Check your EOB to make sure you got the health services it shows you got. It might list more than one health service and provider. For example, if your doctor did a blood test during your visit, your EOB might list the doctor visit and the blood test as separate charges. Check your EOB to see if you will owe any money to one or more providers. If you do, the providers will send you a bill in the mail.

Before you pay any bills, compare the amounts shown on your EOB against the amounts on the provider bills to be sure they match. If you already paid a copay at the time of service, the provider will subtract it from the amount they bill you. Call the insurance company at the number listed on the EOB if:

You see a mistake, such as a charge for a lab test you didn’t get

You have trouble understanding your EOB

The insurance plan is not paying for health services you think should be covered

Keep your EOBs as a record of your insurance. You may be able to see them online at your insurance plan’s website.

Health insurance words to know on your EOB

Here are insurance terms that are used on most EOBs. Your EOBs might not use all of these terms

¦ Allowable amount, also known as Approved amount, Eligible amount, or Covered amount – The amount an insurance plan agrees to pay to an in-network provider for giving covered health care services to insurance plan members. If you go to an out-ofnetwork provider who charges more than the allowable amount, you may have to pay the difference.

¦ Amount not covered, also known as Ineligible amount – An amount your insurance plan does not pay:

¦ If a provider charges more than the allowable amount for a covered health care service, or

¦ If a provider gives you a health care service that is not covered by your health plan.

¦ Amount you owe, also known as Member responsibility – The amount you owe to a provider after your insurance plan has paid its share of the charges. The provider will bill you for the amount. If you already paid a copay at the time of service, the provider will subtract it from the amount they bill.

¦ Benefits – The health care services or items, such as medicines or medical equipment, your plan covers.

¦ Claim – A request for payment that you or your health care provider send to your health insurance company when you get a health care service, such as a doctor visit.

¦ Co-insurance – Your share of the cost for health care services after you have paid your deductible amount each year (see “deductible”). Once you reach your deductible amount, the insurance plan will start sharing the cost of health care with you. For example, if you go for a doctor visit that costs $100, your share may be $20 and your insurance plan’s share may be the remaining $80.

¦ Copayment, also known as a copay – A fixed amount you may pay at the time you receive a health care service – for example, you may pay $15 when you go for a doctor visit.

¦ Deductible – The amount you must pay out of your own pocket for your covered health care services each year – for example, $1,000. Once you reach your deductible amount, your insurance plan will begin sharing the cost with you (see “co-insurance”).

¦ Explanation of Benefits (EOB) – A written explanation from your insurance company about a request for payment, or claim, they have gotten from your provider. You might not get an EOB for 30 days or more after you get a health care service. The EOB shows how much money the insurance plan paid and how much money you must pay (if any) for a health care service or item. The EOB is not a bill. If you owe any money, you will get a bill from your provider.

¦ Plan discounts – The amount you save by using an in-network provider.

¦ Provider – A medical professional or a hospital or other medical facility that provides health care services.

¦ Service, also known as Procedure – Health care you have received from a doctor, hospital or other medical facility.

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