Section title: Requests for Interpretation
RFI #
2371
835 co-insurance discrepancy
Description

The provider is non-participating with the health plan. Health plan states that it is not required to report the actual amount of co-insurance on an 835 ERA because the patient is responsible for the entire amount and the payment is sent to the patient. The information in an ERA and the actual co-insurance amount according to the patient’s health plan terms (and on patient explanation of benefits [EOB]) do not reconcile:
Example:
Patient’s EOB shows co-insurance of $100:
835 Provider ERA shows:
Charged $1000
Allowed $1000
Deductible: $0
Copay/Coinsurance: $0 (vs $100 on the patient EOB)
GRP/RC AMT: $1,000 (PR 100)
Payment: $0
it is permissible for a health plan to provide numerically incorrect amounts on a patient EOB or provider 835 ERA under any circumstances for Amount allowed, deductible amount, co-insurance amount?

Charge: $1000
Allowed $1000
Amount covered: $900
What you owe: $100
Copayments: $0
Deductible: $0
Coinsurance: $100
Not covered: $0
What you owe: $100
Check sent to the patient: $900

Response

No, it is not permissible for the 835 to include amounts that do not accurately reflect the results of the adjudication of the claim. The 835 must report all required adjustment amounts based on the payer’s claim adjudication and understanding of the use of the applicable HIPAA claim adjustment reason codes as it relates to compliance. In the example noted, the entire billed amount is reported correctly as an adjustment with group code PR, as the entire billed amount is Patient Responsibility. As the example notes, the provider is non-participating and the patient is responsible for all charges. It is also noted the health plan paid the patient.

DOCUMENT ID
005010X221