Ineligibly on EOB

[jentjohnson]

The insurance has a limited benefit for office visits. The insurance says the patient responsibility is still $50 copay but they are not paying the rest of the allowable. Does the patient get changed the remaining allowable?

 

[trarut]

Are there are denial or remark codes on the remit that indicate the balance is patient responsibility? I would not guess - I would call the insurance and request clarification and a correct remit if appropriate.

 

[jentjohnson]

No denial code but it does still look like patient responsibility. Worse case scenario, offer self pay after limitation reached?

 

[SharonCollachi]

Still looks like PR to me.

 

[trarut]

Agree with Sharon. These are patient responsibility without a doubt. Look at the Member Liability fields - the Total of each line is the sum of the ineligible amount + the copay due. The total member liability is also equal to the Allowed Charges listed. And last, but not least, the Pay To code is PR (Patient Responsibility).

 

[jentjohnson]

Thank you all. I just needed to see these responses from other certified coders as my higher is not certified. One last question: I'm just entering under ded, copay, coins, whichever our policy wishes to call it? I've never seen a policy for billing/coding...

 

[SharonCollachi]

Yes, just be consistent with what you call it. I would probably call it "coinsurance", as I've had people argue with me that it's not a copay. I can attach a code in my system when I'm posting the payment, and I would attach one that says "Maximum benefit reached."

 

[jentjohnson]

I'm so glad I decided to ask my questions here. I usually forget the forums exist. Thank you, Sharon.