What is Write off - Adjustment amount

Write Off:

This is an amount that the provider has to remove from his books. There are two types of write off: One is contractual write off and the other one is adjustments. Contractual write off are those wherein the excess of billed amount over the carrier’s allowed amount is written off. The fee schedules of each carrier will be loaded in the billing system. When you are posting the EOBs these fee schedules in the system also called system allowed amount would pop up. The difference between the billed amount and the system allowed amount will be the write off, if the EOB allowed amount is less than the system allowed amount. Otherwise the difference between the billed amount and the EOB allowed amount would be the write off.


Adjustments are amounts such as discounts, professional courtesy and other special items that are identified by the provider as those that need not be collected or collected at a lower rate.

A provider is prohibited from billing a Medicare beneficiary for any adjustment (Its a write off) amount identified with a CO group code, but may bill a beneficiary for an adjustment amount identified with a PR group code.

Medicare contractors are permitted to use the following group codes:

CO Contractual Obligation (provider is financially liable);
CR Correction and Reversal (no financial liability);
OA Other Adjustment (no financial liability); and
PR Patient Responsibility (patient is financially liable).

Identifying Contractual Adjustments

The Michigan Department of Community Health (MDCH) defines a contractual adjustment as the difference between the provider’s charges less any third party obligations (payment plus co-pays, deductible and co-insurance).

Contractual adjustment amounts for outpatient hospitals are identified on the payer’s (Medicare or commercial carrier) remittance advice with the following group and adjustment reason codes (ARCs):

CO 42
CO 45

An adjustment amount identified by an ARC not included in this list is not considered a contractual adjustment. Reporting Contractual Adjustments MDCH strongly encourages submission of electronic claims, as the UB-92 claim form does not accommodate reporting contractual adjustment amounts. For electronic claims, the total contractual adjustment amount must be reported in a CAS segment at the claim level.

If a paper claim is submitted, the contractual adjustment amount must be added to the total payment and reported as a single value in Field Locator 54 – Prior Payments. Providers who work with billing agents are responsible for ensuring the contractual adjustment amounts are reported correctly on both electronic and paper claims.

Adjudication of Claims with Contractual Adjustments

Any contractual adjustment amount reported for dates of service on or after July 1, 2006 will be applied as a reduction in charges. This reporting will reduce the provider’s original billed charges for all services to the coinsurance and deductible amounts (net)

For outpatient hospital claims, the total contractual adjustment amount will be prorated across all lines and used to reduce the line charges (e.g., if a claim line’s reported charge is 50% of total charges, 50% of the contractual adjustment amount will be applied as a reduction to the line charges).

What is deductible amount

What is Deductible:

This is an amount that the patient owes the carrier every year apart from the premium. The patient has to pay this amount before insurance started to pay.


 A fixed dollar amount during the benefit period - usually a year - that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles. ¨ Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission. ¨ Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.


Update from Medicare 2017 part b Deductible

CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $183 in 2017 (compared to $166 in 2016). Premiums and deductibles for Medicare Advantage and prescription drug plans are already finalized and are unaffected by this announcement.

1. WHAT DOES DEDUCTIBLE MEAN?

Deductible means you are eligible for Medicaid, except for your income. To get Medicaid, you must use your medical costs to get your monthly income at or below the income limits.

2. WHAT IS A DEDUCTIBLE AMOUNT?

It is the amount of your income that is over the income limit.

3. HOW DO I KNOW IF I HAVE A DEDUCTIBLE?

Your Department of Human Services (DHS) Specialist sends you a letter called the Deductible Notice. It gives your deductible amount and tells how you can get Medicaid. You can get Medicaid when your medical costs are more than your deductible amount. Your Specialist also gives you a Deductible Report form to list your medical bills.

4. CAN MY DEDUCTIBLE AMOUNT CHANGE?

Yes. The changes noted below are examples of what can change your deductible amount. You must let your Specialist know within 10 days of any change in:

• income
• employment
• health insurance coverage and premiums
• the persons living with you
• your address
• other factors that may affect your eligibility.

5. WHAT KIND OF COSTS CAN I USE TO MEET MY DEDUCTIBLE?


Use costs for medical care such as:

• care from hospitals, doctors, clinics, nurses, dentists, podiatrists and chiropractors
• most medicines
• medical supplies and equipment
• transportation to get medical care.

You cannot use costs that your health insurance or Medicare paid for you.

Make sure you tell your Specialist about all medical bills you and your family owe. Tell him or her even if you have not received the bill yet.

It does not matter how long ago you received  the medical services. List your old unpaid bills and each new medical cost you have on your Deductible Report.

6. DO I NEED PROOF OF MY COSTS?

Yes. You must provide proof of your medical costs.

You can use:
• unpaid bills
• paid receipts
• other statements

These statements should show:
• the date of service
• the amount owed or paid
• the person getting the service.

Tell your Specialist if you are having trouble getting this information.

7. DO I HAVE TO PAY MEDICAL BILLS TO USE THEM?

No. But you must have received the medical care before you can use the bill. Paying medical bills is your responsibility. You should contact your provider.

8. WHAT DO I DO WHEN I HAVE ENOUGH BILLS?

Return your Deductible Report and proof of your costs to your Specialist when you have bills or receipts for medical care that total more than your deductible amount.

9. HOW ARE MY BILLS USED TO MEET MY DEDUCTIBLE?

Your Specialist:

• decides which bills or receipts can be used to establish Medicaid eligibility

• can use paid bills to establish eligibility only for the month you received the service

• can use unpaid bills to establish eligibility for any month

• will use the oldest unpaid bills first

• can use any paid or unpaid bill only once to establish eligibility.

10. WHAT HAPPENS NEXT?

Your Specialist will send you a written notice about your Medicaid coverage if:

• your allowable costs are more than your deductible amount

• you still meet the other eligibility requirements.

Your Specialist will tell you if your allowable costs are less than your deductible amount.




Deductible Guideline from BCBS

An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)


What is the overall deductible? Example

For network providers $1,300 individual / $2,600 family; for outof-network providers $1,300 individual / $2,600 family.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.



In insurance policy terms, a deductible is the amount of money which the insured party must pay before the insurance company's own coverage plan begins.  In practical terms, insurance companies include a deductible in their policies to avoid paying out benefits on relatively small claims. A typical auto insurance policy, for example, may carry a $500 deductible. If the owner of that car accidentally hits another car while parking and both drivers agree the damage is minimal, he or she would pay the $500 repair bill out of his or her own pocket. Insurance companies would not encourage a claim for such minor damages.

However, this payment of $500 means that the next accident claim would be covered by the insurance company. The car owner is said to have 'met the deductible' and is now eligible for complete protection. The same holds true for medical insurance. Patients who visit the emergency room for a minor injury or procedure would have to pay out of pocket until they have reached the level of the deductible. If their medical expenses on a visit to the hospital would exceed the deductible, then the insurance company would pay the total charges minus the deductible. In either scenario, the policy holder is almost always held responsible for a small portion of their claims.

The amount of a deductible is almost always proportional to the amount of the premiums (regular payments) charged by the insurers. In order to have a lower deductible, even as low as $0, the policy holder would have to agree to higher premiums. For those who want lower premium payments, they must agree to a higher deductible. There are pluses and minuses to either option- one expensive accident or medical procedure could bring on a very high deductible payment, or a lifetime of good health and few automotive claims could make higher premiums a relative waste of money. Then again, having total coverage with little to no deductible can be a very comforting thought during a crisis, or not paying too much for unneeded coverage can help keep household finances manageable.

A deductible of some kind should be expected with any medical or automotive insurance policy. When shopping for affordable coverage, be sure to ask specific questions about the deductible and other obligations left to the policy holder. An exceptionally low premium rate may signal an equally exceptional high deductible amount. Try to find a balance between affordable premiums and a fair deductible when buying insurance.

Are there services covered before you meet your deductible?

Yes. Preventive services are not subject to the deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible.



Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness.

Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person’s initial enrollment period, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.

Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll. The 2016 rates are as follows:

Deductibles definition

The benefits of the Plan will be available after satisfaction of the applicable Deductibles as shown on your Schedule of Coverage. The Deductibles will be increased in the future in direct proportion to the increase as determined from the cost-of-living adjustments based on the Consumer Price Index (CPI-U).

The Deductibles are explained as follows:

1. The individual Deductible amount shown under “Deductibles” on your Schedule of Coverage must be satisfied by each Participant under your coverage each Calendar Year. This Deductible, unless otherwise indicated, will be applied to all categories of Eligible Expenses, before benefits are available under the Plan.

2. If you have several covered Dependents, all charges used to apply toward an “individual” Deductible amount will be applied toward the “family” Deductible amount shown on your Schedule of Coverage. When that family Deductible amount is reached, no further individual Deductibles will have to be satisfied for the remainder of that Calendar Year. No Participant will contribute more than the individual Deductible amount to the “family” Deductible amount.

The following is an exception to the Deductibles described above:

Eligible Expenses applied toward satisfying the “individual” and “family” Out-of-Network Deductible will apply toward both the Out-of-Network and the In-Network Deductible. However, Eligible Expenses applied toward satisfying the “individual” and “family” In-Network Deductible will not apply toward satisfying the Out-of-Network Deductible.


• 2016 PART A - HOSPITAL INSURANCE (HI)

Deductible: $1,260.00

• Coinsurance
• $315.00 a day for 61st-90th day
:
• $630.00 a day for 91st-150th day (lifetime reserve days)
• $157.50 a day for 21st-100th day (Skilled Nursing Facility coinsurance)
• Base Premium (BP): $407.00 a month
• BP with 10% surcharge: $447.70 a month

What is Co-insurance - how to calculate

Co-Insurance:

This is a part of the allowed amount, which the carrier has determined that the supplementary insurance or the patient is responsible to pay. This will be mentioned clearly in the EOB and should be billed to the secondary carrier or to the patient.

You will pay a small co-insurance payment if you use inpatient respite care for hospice patients.

OPPS Coinsurance

OPPS freezes coinsurance for outpatient hospital at 20 percent of the national median charge for the services within each APC (wage adjusted for the provider’s geographic area), but coinsurance for an APC cannot be less than 20 percent of the APC payment rate. As the total payment to the provider increases each year based on market basket updates, the present or frozen coinsurance amount will become a smaller portion of the total payment until coinsurance represents 20 percent of the total payment. Once coinsurance becomes 20 percent of the payment amount, the annual updates will also increase coinsurance so that it continues to account for 20 percent of the total payment.

Coinsurance - A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.

 Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be “usual, customary and reasonable”.

Coinsurance rates may differ if services are received from an approved provider (i.e., a provider with whom the insurer has a contract or an agreement specifying payment levels and other contract requirements) or if received by providers not on the approved list.

 In addition to overall coinsurance rates, rates may also differ for different types of services.


Coinsurance is the percentage of services that are your financial responsibly. For network benifi ts, your coinsurance amount is 20% for services like lab or x-ray performed outside the doctor's o ce, outpatient care or inpatient care. The 20% coinsurance you pay during a calendar year accumulates toward your out-of-pocket maximum. The out-of-pocket maximum limits your out-of-pocket costs in a calendar year.

Coinsurance The cost sharing of allowable charges by us and you for covered services after you’ve met your deductible, if applicable. Usually shown as a percentage.

Other Liability Out-of-network costs, costs for services that should have had prior review or authorization before they were performed, or any excluded services.


What is an out-of-pocket maximum?

First, an out-of-pocket maximum is not a deductible. The out-of-pocket maximum is the maximum amount you will pay in coinsurance per calendar year. For network benifi ts, the out-of-pocket maximum is $1,000 per person per calendar year. This means that if you have paid $1,000 of coinsurance, for the remainder of that calendar year, HealthSelect will pay 100% for services that typically require you to pay coinsurance (ie., 20%).

Calculating the Medicare Payment Amount and Coinsurance


A program payment percentage is calculated for each APC by subtracting the unadjusted national coinsurance amount for the APC from the unadjusted payment rate and dividing the result by the unadjusted payment rate. The payment rate for each APC group is the basis for determining the total payment (subject to wage-index adjustment) that a hospital will receive from the beneficiary and the Medicare program. (A hospital that elects to reduce coinsurance, as described in §30.1, above, may receive a total payment that is less than the APC payment rate.) The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts. In addition, the amount calculated for an APC group applies to all the services that are classified within that APC group. The Medicare payment amount for a specific service classified within an APC group under OPPS is calculated as follows:

Step 1 - Apply the appropriate wage index adjustment to the payment rate that is set annually for each APC group;

Step 2 - Subtract from the adjusted APC payment rate the amount of any applicable deductible;

Step 3 - Multiply the adjusted APC payment rate, from which the applicable deductible has been subtracted, by the program payment percentage determined for the APC group or 80 percent, whichever is lower. This amount is the preliminary Medicare payment amount;

Step 4 - Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less the amount of any applicable deductible. If the resulting amount does not exceed the annual hospital inpatient deductible amount for the calendar year, the resulting amount is the beneficiary coinsurance amount. If the resulting amount exceeds the annual inpatient hospital deductible amount, the beneficiary coinsurance amount is limited to the inpatient hospital deductible and the Medicare program pays the difference to the provider.

Step 5 - If the wage-index adjusted coinsurance amount for the APC is reduced because it exceeds the inpatient deductible amount for the calendar year, add the amount of this reduction to the amount determined in Step 3 above to get the final Medicare payment amount.


EXAMPLE 1:

The wage-adjusted payment rate for an APC is $300; the program payment percentage for the APC group is 70 percent; the wage-adjusted coinsurance amount for the APC group is $90; and the beneficiary has not yet satisfied any portion of his or her $100 annual Part B deductible.

A. Adjusted APC payment rate: $300.

B. Subtract the applicable deductible: $300 - $100 = $200.

C. Multiply the remainder by the program payment percentage to determine the preliminary

Medicare payment amount: 0.7 x $200 = $140.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less any unmet deductible to determine the coinsurance amount, which cannot exceed the inpatient hospital deductible for the calendar year: $200 - $140 = $60.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation. $140 + $0 = $140.

In this case, the beneficiary pays a deductible of $100 and a $60 coinsurance, and the program pays $140, for a total payment to the provider of $300. Applying the program payment percentage ensures that the program and the beneficiary pay the same proportion of payment that they would have paid if no deductible were taken.

If the annual Part B deductible has already been satisfied, the calculation is as follows:

A. Adjusted APC payment rate: $300.

B. Subtract the applicable deductible: $300 - 0 = $300.

C. Multiply the remainder by the program payment percentage to determine the preliminary

Medicare payment amount: 0.7 x $300 = $210.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the amount of the inpatient hospital deductible for the calendar year: $300 - $210 = $90.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation: $210 + $0 = $210.

In this case, the beneficiary makes a $90 coinsurance payment and the program pays $210, for a total payment to the provider of $300.


EXAMPLE 2:

This example illustrates a case in which the inpatient hospital deductible limit on coinsurance amount applies. Assume that the wage-adjusted payment rate for an APC is $2,000; the wage-adjusted coinsurance amount for the APC is $900; the program payment percentage is 55 percent; and the inpatient hospital deductible amount for the calendar year is $776. The beneficiary has not yet satisfied any portion of his or her $100 Part B deductible.

A. Adjusted APC payment rate: $2,000.

B. Subtract the applicable deductible: $2,000 - $100 = $1,900.

C. Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount: 0.55 x $1,900 = $1,045.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the inpatient hospital deductible amount of $776: $1,900 - $1,045 = $855, but the coinsurance is limited to $776.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation ($855 - $776 = $79). $1,045 + $79 = $1,124.


In this case, the beneficiary pays a deductible of $100 and a coinsurance that is limited to $776 and the program pays $1,124 (which includes the amount of the reduction in beneficiary coinsurance due to the inpatient hospital deductible limitation) for a total payment to the provider of $2,000.

For calendar year 2002, the national unadjusted copayment amount for an ambulatory payment classification (APC) is limited to 55 percent of the APC payment rate established for a procedure or service. In addition the wage-adjusted copayment amount for a procedure or service cannot exceed the inpatient hospital deductible amount for 2002 of $812. These changes were implemented by changes to the OPPS Pricer effective for services furnished on or after January 1, 2002.

What is Allowed Amount

What is fee amount and allowed amount 

A fee is the price a healthcare provider charges for a product or service. This is similar to each product like electronic item comes with price. Each practice calculates the fee based on the Medicare allowed amount for that year and that area.


The "allowed amount" is one medical insurer pays which is not necessarily to the exact fee practice set the fee. This is like what medical insurers typically pay the allowed charge or the usual, customary, and reasonable fee for a product or service within the specific section of the country.

As Example practice set $100 for Fever consultation which is the Fee amount but insurance pays only $80 which is allowed amount in this case.

The difference between fee and allowed amount usually refers as Write off amount.
 


Allowed Amount :

This is the amount allowed by the carrier. Not all carriers and in all circumstances allow the entire amount billed. Certain carriers have fee schedules based on which they make payments. These fee schedules determine the allowed amount. A Fee Schedule is a list of reimbursement amount for each procedure. These vary according to various localities. This allowed amount is the maximum that a carrier will pay for a particular procedure.

After reviewing the definitions in rules or provided by the health insurers, OFM found that:

* Allowed amount is the maximum amount that a payer will pay a provider for a service.

* Allowed amount applies to services that are included or allowed in the health care plan or the government program.

* Allowed amount applies to services provided by providers who are contracted with the health care plan (in-network).

* Allowed amount varies for providers who are not contracted with the subscriber’s health care plan (out-of-network).

* Allowed amount may not cover all the provider’s charges. In some cases, subscribers may have to pay the difference.

* Allowed amount may be determined by a fee schedule such as Medicare’s.

* Usual customary and reasonable (UCR) amount is sometimes used to determine the allowed amount.

* Oregon is the only state that defines allowed amount

Uniform Glossary

Allowed amount – Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference.

UCR (usual, customary and reasonable) – The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Allowable Amount

The Allowable Amount is the maximum amount of benefits BCBSTX will pay for Eligible Expenses you incur under the Plan. BCBSTX has established an Allowable Amount for Medically Necessary services, supplies, and procedures provided by Providers that have contracted with BCBSTX or any other Blue Cross and/or Blue Shield Plan, and Providers that have not contracted with BCBSTX or any other Blue Cross and/or Blue Shield Plan. When you choose to receive services, supplies, or care from a Provider that does not contract with BCBSTX, you will be responsible for any difference between the BCBSTX Allowable Amount and the amount charged by the non-contracting Provider. You will also be responsible for charges for services, supplies, and procedures limited or not covered under the Plan, Deductibles and any applicable Out-of-Pocket Maximum amounts.


Medicare Glossary of Terms

Medicare approved amount – In Original Medicare, this is the amount a doctor or supplier who accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

WAC 182-550-1050 Hospital services definitions

Allowed amount – The initial calculated amount for any procedure or service, after exclusion of any nonallowed service or charge, that the agency allows as the basis for payment computation before final adjustments, deductions and add-ons.

Premera Blue Cross

Allowable charge – This plan provides benefits based on the allowable charge for covered services. We reserve the right to determine the amount allowed for any given service or supply. The allowable charge is described below

What is EOB - Explanation of Benefits

Explanation of Benefits

Explanation of Benefits or EOB is the detailed statement of the carrier’s determination of the claims processed. The determination can result in a payment or a denial.


The Explanation of Benefits contains the following information:

Name of the payer, Name of the provider, Pay-to address, Name of the patient, Name of the member, his id #, date of service, procedure code, amount billed by the provider, amount allowed by the payer, co-insurance, deductible, amount paid by the payer. The amount paid by the payer is equal to the amount shown by the check.

What exactly is the EOB, I mean, what do the letters stand for.

Simple: EOB is short for Explanation of Benefits which is a notification sent by the medical insurance company administrators after processing a medial insurance claim.

The EOB explains the total amount the health care provider billed for medical services, the amount paid under the insurance contract, and who was paid. Patients should keep a copy of their bills from the health care provider of medical services to compare them to the EOB. 


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.

Some related terms


EXPLANATION OF BENEFITS:

The time frame that payor gives to the provider to submit the claims and get reimbursed. Timely filing limit starts from date of service in case of outpatient claims and from date of discharge in case of inpatient claims.

TIMELY FILING LIMIT: The time frame that payor gives to the provider to submit the claims and get reimbursed. Timely filing limit starts from date of service in case of outpatient claims and from date of discharge in case of inpatient claims.

APPEALS TIMELY FILING LIMIT: The time frame that the insurance company gives to the provider to submit the claims and get reimbursed after the claim has been denied. Appeals limit starts from the date of denial