Scenario: The ERA for the CCF account has a partial payment.
For example:
$500 billed
Medical ERA
$300 deductible from the Medical ERA (PR1)
$200 write off (CO45)
CCF ERA
$125 paid from the patients CCF account (OA187)
$125 previous medical processing (OA23)
$175 remaining amount owed by patient (PR96)
Today on the 835, we identify the remaining patient responsibility as PR96, patient responsibility, not covered.
• Does the provider have any suggestions on codes to use in place of PR96 to better communicate that the remaining amount is the responsibility of the patient?
• One suggestion we received is to use PR1 (deductible) or PR2 (coinsurance), as was indicated on the original medical ERA.
-Does the provider agree this code would communicate the message clearly?
-Would it cause any confusion to receive this code on both the medical and the CCF ERAs?
The information supplied does not accurately support the COB method of handling a high deductible health plan processng.
The OA 23 amount should be represented as $200.00 as that is the write off amount (if there was a paid amount that would also be included in this OA 23 amount).
There is then $300.00 left of which the $125.00 amount is being paid out of the CCF account then there is a remainder of $175.00 that the patient owes the provider and that amount in both the initial remit from the plan should be reflected as PR – Patient Responsibility 1 – Deductible.
CLP04 = 125
CAS*OA*23*200~
CAS*PR*1*175~