Insurance Payments

When Medicare is secondary, information about how the primary claim was adjudicated must be captured. This information is automatically captured if the primary insurance payment was posted via Electronic Remittance. However, if the primary insurance payment is entered manually, there are additional steps required to send a proper MSP electronic claim.

MedSuite's secondary payment information module collects primary payment adjudication data at both the claim-level and the service line-item level. The claim-level informaiton is not generally required. However, if it appears on the primary EOB, it should be entered into MedSuite.

Reimbursement Percent	Enter the percentage at which the primary claim was reimbursed. On an "80/20 plan", this is the 80%, not the 20%.
HCPCS Payable Amount	Enter the HCPCS payable amount for the claim
End-Stage Renal Disease Amount	Enter the amount if applicable
Non-Payable Professional Component Billed Amount	Enter the amount if applicable.
Remarks 1-5	Select up to 5 Remark Codes from MedSuite's Payment Reason Codes We have seen many payers report ANSI Remark Codes in their Electronic Remittance Advice, but payer-specific non-ANSI Remark Codes on hard-copy EOBs. CMS requires the only ANSI Remark Codes be reported on MSP electronic claims. Your staff will have to "translate" from the payer-specific remark codes on hard-copy EOBs to the ANSI Remark Codes required by Medicare
Amount Fields	Neither the Patient Paid Amount nor the Interest Amount would generally be reported to Medicare. Patient Payments (Co-Pays) would be entered on the Svc Level Secondary Information screen.

Claim-level "adjustment" amounts may be reported by the primary payer. These amounts are not necessarily "adjustments" in the common usage of the term with regard to contractual adjustments. In this context, an "adjustment" is any amount other than the primary payer's payment amount that either represents the patient's responsibility (Deductible, Co-Insurance, or Co-Payment) or reduces the patient's responsibility (Contractual Write-Offs, Recoups, etc). Click on New, Edit, or Delete to add, change or delete a Claim-Level Adjustment.

Claim-Level Adjustments should only be entered if the EOB reports any. Normally adjustments are reported at the Svc (Line-Item) Level.

Type	The Claim-Level Adjustment Type is "hard-coded" to "CAS". This value is required in the ANSI Claims specification.
Group Code	The Group Code is used to classify the "adjustment" amounts into categories and when used in combination with a Remark Code is frequently seen on EOBs: Allowable values for the Group Code are the following: Description Reported Contractual Obligation CO Correction and Reversals CR Other Adjustment OA Payer Initiated Reduction PI Patient Responsibility PR You may notice that the "reported" codes when used in combination with a Reason/Remark code are familiar to you. Values such as PR-1 and CO-42 are frequently seen on EOBs.
Reason Code	Select the Reason/Remark Code from MedSuite's Payment Reason Codes.
Amount	Enter the amount of the adjustment.

In order for Medicare to properly adjudicate MSP claims, Medicare needs to know how the primary payer adjudicated the claim. This is normally accomplished by the primary payer reporting "line-item level" amounts and remarks for the secondary payer. The Svc (Line-Item) Level Secondary Information is entered by highlighting a specific line-item and then adding the necessary adjustments.

If no Svc-Level adjustments were previously entered, the "Svc Defaults" button will be enabled. This allows the user to create certain default values for each line item. The defaults are created as follows:

Group Code	Reason Code	Source of Amount
CO	45	Line-Item Adj 1
PR	1	Line-Item Deduct
PR	2	Line-Item Open (minus) Line-Item Deduct

MedSuite "assumes" that the difference between the Open balance on a charge and the Deduct amount is "Coinsurance" and not "Co-Pay". If these assumptions are incorrect for any specific situation that you encounter, then do not select the Svc Default button or correct the adjustments in order to properly reflect the amounts on your EOB.

Like Claim-Level adjustments, these amounts are not necessarily "adjustments" in the common usage of the term with regard to contractual adjustments. In this context, an "adjustment" is any amount other than the primary payer's payment amount that either represents the patient's responsibility (Deductible, Co-Insurance, or Co-Payment) or reduces the patient's responsibility (Contractual Write-Offs, Recoups, etc). Highlight to applicable service line item in the top gird on the screen and then click on New, Edit, or Delete to add, change or delete Svc-Level Adjustment.

Type	The Claim-Level Adjustment Type is "hard-coded" to "CAS". This value is required in the ANSI Claims specification.
Group Code	The Group Code is used to classify the "adjustment" amounts into categories and when used in combination with a Remark Code is frequently seen on EOBs: Allowable values for the Group Code are the following: Description Reported Contractual Obligation CO Correction and Reversals CR Other Adjustment OA Payer Initiated Reduction PI Patient Responsibility PR You may notice that the "reported" codes when used in combination with a Reason/Remark code are familiar to you. Values such as PR-1 and CO-42 are frequently seen on EOBs.
Reason Code	Select the Reason/Remark Code from MedSuite's Payment Reason Codes.
Amount	Enter the amount of the adjustment.

For each line-item, the sum of all service-level "adjustment" amounts entered must balance to the following formula:

Basically, all of the money for each charge must be accounted for either as a payer "adjustment" or "reduction" or as patient responsibility. Frequently, the primary makes multiple payments or first denies and then pays a claim. MedSuite's MSP processing adds ALL primary information from ALL payments together. The "balancing" noted above needs to be peformed across all payments.