Monday, June 28, 2010

What is PR and OA - denial EOB

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.

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