Question

As with a Medicare RA, when a commercial RA is received, before posting payments and preparing secondary claims that may be required you must carefully review it. When analyzing an RA from a commercial carrier, you must be familiar with the guidelines of that carrier’s particular plan. The type of services covered and the percentage of the coverage will vary, depending on whether the plan is a fee-for-service plan, a managed care plan, a consumer-driven health plan, or some other type. The allowed amounts for each procedure will also vary with different plans, depending on the fee schedule decided upon in the contract between the payer and the provider. The contract will also specify whether there is a discount on the fees.

 

In Claim Case Study 16.4, an RA is received from Anthem BCBS that is a fee-for-service plan with an 80-20 coinsurance and a $250 deductible. The first page of the RA shown in Figure 16.4 contains claim information for two patients who have secondary insurance plans through their spouses. (The primary claim for both 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).

 

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 Anthem BCBS RA (Figure 16.4), prepare secondary claims for both Anthem BCBS patients. You will need to base the secondary claims on the primary claims you created for each patient in Chapter 15.

 

Secondary Claim: Claim Case Study 16.4B
Patient: Ruff, J.
Primary Claim: Claim Case Study 15.18
Patient NO.: AA031

Answer 1

Commercial RA/EOB Analysis

1. Anthem BCBS

2. $200; $50; 80 percent

3. $76 ($50 to fulfill her 2016 deductible plus $26 patient liability)

4. The allowed amount for the procedure is $180. The carrier will pay for 80 percent of covered services once the deductible is met. In this case, $50 is owed toward the deductible. Therefore, the amount due for the service is reduced to $130 ($180 -$50 deductible). Anthem BCBS then pays 80 percent of $130 to the provider, or $104.

5. 80 percent; yes

6. $15; 20 percent

7. Yes, a secondary claim should be sent to the secondary payer so that the payer has a record of benefits received or denied from the primary payer as well as how much Jean Ruff has paid toward her deductible for the year.

8. Giroux: $180; $20.80 (80% of $26.00, assuming that her secondary plan covers the routine annual physical)

Ruff: $75; $0 (100% of $15 = $15, minus the $15 copay)

Preparing Secondary Claims

See the answer keys for Claim Case Studies 16.4 A-B below, for Anthem BCBS patients Giroux and Ruff.

ANSWERS TO CALCULATING PATIENTS’ BALANCES

CLAIM CASE STUDY	PATIENT	PATIENT BALANCE
16.5	Wendy Walker	$0
16.6	Walter Williams	$0
16.7	Donna Gaeta		$126.80
16.8	Lakshmi Prasad	$23.60
16.9	Joseph Zylerberg		$15
16.10	Shih-Chi Yang	$0
16.11	Andrea Spinelli	$0
16.12	Nancy Lankhaar	$0
16.13	Donald Aiken		$0
16.14	Eric Huang		$34.60
16.15	Isabella Neufield		$0
16.16	Alan Harcar		$50.00
16.17	Jose Velaquez		$0
16.18	Wilma Estephan		$7.00
16.19	John O’Rourke	$0
16.20	Sylvia Evans		$0
16.21	Karen Giroux		$7.20
16.22	Jean Ruff		$15
16.23	Mary Anne Kopelman		$0
16.24	Otto Kaar		$0

Claim Case Study 16.4 A

Claim Case Study 16.4 B