This documentation is to help correctly create and send secondary electronic claims.
Once the primary payer’s payment and EOB for a patient are received, a Secondary Electronic Claim can be created for the patient. Not all payers will accept secondary eClaims. If there are any questions about which payers will accept secondary eClaims, please contact the payers directly. MacPractice does not have this information.
Similar to sending a copy of an EOB with a secondary paper claim, EOB information is required on a secondary eClaim. The EOB Columns need to be turned on and filled in while entering in the payment for the primary claim in the Primary Payment Window. Check the box next to Use EOB Columns.
After checking Use EOB Columns some additional columns will be added to the payment window for Deductible, Co-Insurance, Copay, Disallowed, Reason Code and ICN. The payment line will turn red and will not save until the EOB columns have been properly filled out.
The Disallowed amount is calculated from the total Fee Amount minus the Payment. Entering information in the Deductible, Co-Insurance and Copay columns will reduce the amount in the Disallowed column. If the Disallowed amount is zero, the insurance payment can be saved. If there is any remaining Disallowed Amount, it must be accompanied by an appropriate Reason Code. The Reason Code identifies the reason why the primary Payer did not pay the entire amount, aside from the Deductible, Co-Insurance and Copay. The reason code can be found on the primary payer's EOB.
The Disallowed amount is often confused with a write-off. The Disallowed amount is the amount that was not paid after subtracting all payments (patient and insurance) and any insurance deductions. Often times the write-off and the Disallowed amount will be the same amount, but they are separate items. See the formulas for calculating both Disallowed and write-off below:
[Fee] - [Paid] - [EOB Columns "Deductible," "CoInsurance" and “Copay”] = [Disallowed amount]
[Fee] - [Allowed] = [Write Off]
Some payers use their own set of reason codes to disallow payment, however electronic claims require all reason codes to be sent in a HIPAA-mandated format. A list of HIPAA approved reason codes can be found in the Internet Ability in MacPractice by clicking on Claims Adjustment Reason Codes in the sidebar or by visiting the WPC website. If the payers are not using the HIPAA standard list, the payer specific list will need to be acquired.
Each Reason Code will also need to be accompanied by a Group Code. Group Codes are the two digit alpha-characters in front of the Reason Code.
With the EOB columns turned on, the payer’s Internal Control Number or ICN can be entered in the last column.
Explanation of Claim Adjustment Group Codes
- CO - Contractual Obligations: This group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write-off for the provider and are not billed to the patient.
- CR - Corrections and Reversals: This group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim. When correcting a prior claim, CLP02 (claim status code) needs to be 22. See ASC X12N Health Care Claim Payment/Advice Implementation Guide (835) section 2.2.8 for complete information about corrections and reversals.
- OA - Other Adjustments: This group code should be used when no other group code applies to the adjustment.
- PI - Payer Initiated Reductions: This group code should be used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer, for example a medical review or professional review organization adjustments.
- PR - Patient Responsibility: This group should be used when the adjustments represent an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.
EOB columns will need to be filled out for each procedure being submitted on the eClaim. If the disallowed amount is actually the copay, co-insurance or deductible amount, the amount must be entered in the appropriate column. Using an incorrect column will cause the claim to be unbalanced and reject at the clearinghouse.
Any amount added to the Deductible and Copay amounts will be sent to the Patient portion if applicable.
Once the correct information is entered in the primary payment window, the secondary electronic claim can be created. Select the same charges that were sent in the primary claim, select the Print menu, and choose Create Insurance Claim. The Command-P keyboard shortcut will also create the claim. Be sure that the secondary payer is listed in the Claim Creation sheet and that the correct eClaims template is selected. The Secondary Claim checkbox should be checked in the claim creation window and the Ins. Paid column should show the primary payer's payment. Select OK and the claim will be created.
The ledger will notate in the ‘Code’ column that the claim is a Secondary eClaim.