Check "Use EOB Columns" to add additional fields to the payment window. These fields are generally used on primary payments, before generating a secondary eClaim. Secondary eClaims require that the EOB information is included on the claim, similar to sending a copy of a paper EOB with a secondary paper claim. EOB information entered in the primary payment window will pull forward onto a secondary eClaim file. Checking the Use EOB Columns checkbox will add the following columns to the procedure summary table: Deductible, Co-Insurance, Copay, Disallowed, Reason Code and ICN. If the insurance payment is applied to the open charge(s) and there is a portion of the charge(s) that has not yet been paid, the payment line will turn red. This is because the Reason Code is now a required field, and you will be unable to save the payment until all applicable reason code fields have been filled out. The remaining EOB columns may be filled out as well, although this is not required in order to save the payment in MacPractice.
The deductible, coinsurance, and copay columns will appear in the procedure summary table of the Payment Window when Use EOB Columns is checked. If the disallowed amount is actually the copay, co-insurance or deductible amount, it is important that you fill out the amount in the appropriate column. This information should be located on the EOB you received from the primary payer. Using an incorrect column or failure to fill in these columns when applicable may cause your secondary eClaim to be unbalanced or rejected.
Any amount added to the Deductible and Copay amounts will be sent to the Patient portion if applicable.
The Disallowed amount will be auto-populated when applying a payment towards a procedure and using EOB columns. It 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, you may save the insurance payment. If there is any remaining Disallowed Amount, it must be accompanied by an appropriate Reason Code.
MacPractice will use the following formula to calculate the Disallowed amount:
Fee - Payment - (Deductible + Coinsurance + Copay) = Disallowed amount
Any remaining Disallowed amount requires a corresponding Reason Code.
If the Disallowed is zero, no additional Reason Code is required.
With the EOB columns turned on in the payment window, you will also be able to enter the claim ICN number, or the payer's Internal Control Number. However, the ICN number is not sent on claims and is purely informational.
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 column will appear in the payment window when Use EOB Columns is checked. A reason code must accompany a disallowed amount on a primary insurance claim in order for the corresponding secondary eClaim to be accepted. You will find the reason code on your primary payer's EOB.
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 your Internet Ability in MacPractice by clicking on Claims Adjustment Reason Codes in the sidebar.
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.
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.
- 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 adjustment represents an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.
You should use the reason code indicted on the EOB you receive from the payer. When in doubt as to which reason code to use, please consult the WPC Website or contact the patient's primary insurance company. MacPractice Support will be unable to tell you which reason codes to use on an insurance payment.