Question

When a practice receives an RA from a carrier, the payment received for each procedure is posted to each patient’s account. If any patients on the RA have secondary coverage, secondary claims are then prepared unless they have automatically crossed from the primary to the secondary payer. Before doing so, however, the practice analyzes the RA to make sure the payments received are in keeping with what is expected given the office’s fee schedule, the patient’s insurance plan, and any deductibles or copayments that may be required from the patient.

 

In Claim Case Study 16.3, an RA is received from Medicare Nationwide. The first page of the RA shown in Figure 16.3 contains claim information for four patients who have secondary insurance plans. (The primary claim for each of these patients was created in Chapter 15.) Answer the following questions based on the information in the RA before preparing the patients’ secondary claims.

 

Prepare the claim for this case by completing the appropriate fields in the CMS-1500 form provided. Accuracy is important. Please note that tabbing through the form works inconsistently; it is recommended that you click in each field for which you want to enter information. For the purposes of Connect, all dates should be entered in 8-digit format (XX in MM field; XX in DD field; XXXX in YY field) except for Item Number 24, where the dates should be entered in 6-digit format (XX in MM field; XX in DD field; XX in YY field).

Per NUCC Guidelines, use SOF in this exercise for Signature on File if appropriate. Also, per NUCC guidelines, do not include the decimal point in the diagnosis code(s) entered in Item Number 21. Functionality TIP: if you can't see the entire form and don't have scroll bar functionality (especially if you click "Check my work"), click anywhere in the form and use the arrow keys on your keyboard to help you navigate.

 

Billing Provider: Valley Associates PC
NPI: 1476543215
Employer ID Number: 16-1234567
Address: 1400 West Center Street, Toledo, OH 43601-0213
Telephone: 555-967-0303
Rendering Provider: Christopher M. Connolly, MD
NPI: 8877365552
Assignment: Accepts
Signature: On File (01/01/2029)

 

Preparing Secondary Claims

 

Using the information shown in the Medicare Nationwide RA (Figure 16.3), prepare secondary claims for the following Medicare patient. You will need to base the secondary claim on the primary claim you created for the patient in Chapter 15. 

 

Remember that you are preparing secondary claims for practice: Ignore the note on the RA saying that the claims have crossed over the particular secondary payer.

 

Secondary Claim: Claim Case Study 16.3B
Patient: Lankhaar, N.
Primary Claim: Claim Case Study 15.8
Patient No.:AA017

Answer 1

Medicare RA/EOB Analysis

1. Three (Zylerberg, Lankhaar, and Aiken; Estephan still owes $7.00)

2. No

3. The VAPC amounts and the approved amounts are the same.

4. 20% of $103, or $20.60; 100%

5. 20% of $17, or $3.40; 100%, or $3.40

6. No, it would be more efficient to send the secondary claims first. After the RAs have been received from the secondary carriers, patients’ balances can be recalculated to obtain a final amount due; then patients can be billed.

7. $1.40; $7.00

8. Because she still owes $7.00 towards her 2016 deductible. Medicare pays for 80 percent of covered services once the deductible has been met. Therefore, the allowed amount of $14.00 minus the $7.00 deductible due leaves $7.00 remaining. Medicare will pay for 80 percent of the remaining $7.00, which is $5.60.

9. Zylerberg: $11.40 ($26.40- $15 copay) Lankhaar: $ 5.60

Aiken: $17.20

Estephan: $ 1.40 ($8.40 - $7.00 deductible to be paid by the patient)

Preparing Secondary Claims

See the answer keys for Claim Case Studies 16.3 A-D below, for Medicare patients Zylerberg, Lankhaar, Aiken, and Estephan.

Claim Case Study 16.3 A

Claim Case Study 16.3 B

Claim Case Study 16.3 C

Claim Case Study 16.3 D