Re: Credit Reserve

[Jim Whicker]

Jonathan - I'm running this issue by a provider list serve that I participate with to see if I can get some feedback... it appears that most providers are not familiar with this concept - although I've heard of it, I'm not experienced with it.  As soon as I get some useful feedback, I'll share it.  JIM >>> <[EMAIL PROTECTED]> 07/24/01 03:58PM >>> I have a basic question.. what is an adjustment?  When I researched this question I came up with the following information.  This is how I concluded that that Credit Reserve was indeed an adjustment.  FYI.. "Credit Reserve" must be expressed  at the line level and the claim level.  "Credit Reserve" is only a factor when paying secondary or tertiary claims. 1.  What is an adjustment?  This is found on Washington Publishing site when you click on the Adjustment Reason Codes and click on List Description CLAIM ADJUSTMENT REASON CODES Introduction Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. Claim adjustment reason codes are used in these ASC X12N version 4 release 1 transaction set implementation guides: *** We are meeting the definition of "...claim or service line was paid differently than it was billed..." 2.  I don't believe that a claim with Credit Reserve will balance. Page 19 of the 835 states Amount 1 (submitted charge for this service) - Amount 2 (monetary adjustment amount applied to this service) = Amount 3 (Paid Amount for this Service).  How can I balance this line when the charge minus the adjustment will not equal the paid amount..assuming there won't be a credit reserve amount adjustment code to show the credit reserve amount applied to the line. Thanks! Jonathan Showalter Omaha NE  USA 402-343-3381 [EMAIL PROTECTED] ------------------( Forwarded letter 1 follows )-------------------- Date: Tue, 24 Jul 2001 07:41:40 -0400 To: JONATHAN.SHOWALTER Cc: [EMAIL PROTECTED], [EMAIL PROTECTED] From: [EMAIL PROTECTED] Subject: Re: New Adj Reason Code Jonathan, What we have seen so far is that those responding to your message do not feel that you need a claim adjustment reason code. This is not an adjustment to the claim.  That tells us how you will not tell the providers.  As to other options, there are three that I can see off the top of my head. 1 - the providers do not need this information because people are the issue with your scenario, but the 835 is computer processed and will accept the payment without question. To do otherwise requires that the vendor program the computer to compare actual payment with  some expected payment and report both over and under payments to the office staff. Not all systems will program in the checking, and I would guess that most of those that do will only report out under payments. 2 - Use the Claim level REF segment to report a Class of Contract Code that identifies the contract type.  You control the coding here and can assign codes/definitions that identify which types of accounts participate in the Credit Reserve.  Then, providers will not be suprised if they receive a higher payment than expected on that class of contract.  (I think that this is the approach I would prefer) 3 - Use the MIA or MOA segment to report a Claim Payment Remark Code identifying that the "Normal Patient Responsibility amount has been partially or completely paid through a credit reserve account".  These codes are available through Washington Publishing.  They are owned by CMS (HCFA) and you can request a new code online.  I would recommend that you word your code request to be as generic as possible, so that others will be able to use it as well. Thanks, Bob PS - any on the listserve interested in adding their two cents or preference, please do so.                     JONATHAN.SHOWALTER@                     bcbsne.com                 To:     robert.poiesz@highmark. com                                                cc:                     07/23/01 05:05 PM          Subject:     Re: New Adj Reason Code Bob, I don't think I have clearly communicated the issue clearly.  I cut a single check to a provider for a claim for $125 dollars (total charges of claim $125)... They normally would expect to get $75 dollars in this case.  I need to tell the provider what amount I paid as per our fee schedule and how much I paid them as part of Credit Reserve.  If I don't tell them why, they don't know what to do with the extra payment because they are smart enough to know and honest enough not to just take the money without asking questions about how the amount should be applied to the account. Without this code, how will I tell the provider the reason they received an extra $50 for this claim? Thanks! Jonathan Showalter Omaha NE  USA 402-343-3381 [EMAIL PROTECTED] ------------------( Forwarded letter 1 follows )-------------------- Date: Mon, 23 Jul 2001 13:38:02 -0400 To: JONATHAN.SHOWALTER From: [EMAIL PROTECTED] Subject: Re: New Adj Reason Code Jonathan, I messed up and did not include you on the message to the list serve. Here are the responses I am getting: We refer to this in our system as "COB Savings".  Normally, the provider bills us for $100 and also reports the $20 co-pay received from the patient. Assuming that there are no other adjustments, we would prepare a check to the provider for $80 and a check for $20 to the insured.  The provider has no need to know about the COB Savings, so we don't inform them of it. Neil A. Bryson The Calends Group, Inc. 219-485-0273 x 234 In response to the need of a new adjustment reason code for the 835 to report this a "payment from credit reserve":  I do not believe that this would be a true adjustment.  The calculation in the 835 is the submitted charges less adjustments equals the payment, and if co-pay is not being adjusted from the charges, there is no need to report this information. The states/providers/payers that fall within the utilization the "credit reserve" should have knowledge of this activity, realize that it is not deducted, thus the 835 calculation holds true. Thank You, Desiree Van Lieu FCSO/FISS [EMAIL PROTECTED] I will foward others as I get them and send out any response you would like me to deliver. Bob Bob                     JONATHAN.SHOWALTER@                     bcbsne.com                 To: robert.poiesz@highmark. com                                                cc: [EMAIL PROTECTED] org, [EMAIL PROTECTED]                     07/23/01 11:33 AM          Subject:     Re: New Adj Reason Code The provider needs to know about this amount because it is above the amount they would normally get paid.  For example, service X is submitted for $100 dollars and the fee schedule says pay the provider $80.  Without COB/Credit Reserve Savings, you would show that the patient is responsible for the other $20 dollars and that would be the end of the story....but.... in the case of COB/Credit Reserve Savings the providers check is written for an extra $20 they want to know why.  Our customer service dept is telling me that providers ask why they were "overpaid" all the time... at least that is how they look at it until they realize we are paying the subscriber liability for the subscriber. Thanks! Jonathan Showalter Omaha NE  USA 402-343-3381 [EMAIL PROTECTED] ------------------( Forwarded letter 1 follows )-------------------- Date: Mon, 23 Jul 2001 08:42:18 -0400 To: JONATHAN.SHOWALTER, [EMAIL PROTECTED] Cc: [EMAIL PROTECTED] From: [EMAIL PROTECTED] Subject: Re: New Adj Reason Code Jim & Jonathan, The 835 requires adjustments only when there is a change to the amount being paid. As I see this situation, the payment from this 'account' would not need to be reflected in the 835 because this payment would be offsetting patient responsibility adjustments.  What I would recommend is not to report any of those adjustments. For instance, if there is a claim for $100 where a 20% copay would apply, the norm would be to report a CAS*PR*3*20~ adjustment.  Because this is now going to be paid out of this new account, you can eliminate reporting the copay to the provider.  The alternative would be reporting offsetting adjustments with some new (call it XX) adjustment code as CAS*PR*3*20**XX*-20~, and I don't think that this level of information is needed. My assumption in this is that the provider does not have a need to know where the payment comes from, just that the payment is being made. Obviously, the patient DOES care about this, but the patient never gets an 835. Bob PS - I am copying the Claim Payment Listserve to get other comments if someone disagrees with this analysis.                     "Jim Whicker"                     <ARJWHICK@ihc        To: <[EMAIL PROTECTED] m>, <[EMAIL PROTECTED]>                     .com>                cc:                                          Subject:     Re: New Adj Reason Code                     07/23/01                     08:13 AM Bob - Jonathan posted this to the WEDI listserve ... was wondering if the 835 committee had ever discussed this topic and had suggestions?? Jim >>> [EMAIL PROTECTED] 07/20/01 11:04AM >>> Some of you may be aware that a handful of states (Nebraska being one) have adopted the concept of "Credit Reserve/COB Banking".  This allows a member to accumulate money saved from COB into an account.  Money is then paid to the provider/member from this account when charges are the subscribers liability. At issue is the fact that no HIPAA Adjustment Reason Code exist to express this to the provider.  Has anyone on the list developed the text for such a code.  I would like to formulate a request for a new claim adjustment reason code but one that everyone could use for this reason. Perhaps something as simple as "Payment from Credit Reserve"? Have any of you thought about how to express this if it applies to you?  I have not found an adjustment reason code to do this.. have any of you?  If it is true that a no current adjustment reason code exist today, what do you think about the suggested text of the message above?  Is it clear to providers and payers? Thanks! Jonathan Showalter Omaha NE  USA 402-343-3381 [EMAIL PROTECTED] ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request.