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After checking Use EOB Columns some additional columns will be added to the payment window for Deductible, Co-Insurance, Copay, Disallowed, Reason Code and ICN. The payment line will turn red and will not save until the EOB columns have been properly filled out.

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Disallowed Amount

The Disallowed amount is calculated from the total Fee Amount minus the Payment. Entering information in the Deductible, Co-Insurance and Copay columns will reduce the amount in the Disallowed column. If the Disallowed amount is zero, the insurance payment can be saved. If there is any remaining Disallowed Amount, it must be accompanied by an appropriate Reason Code. The Reason Code identifies the reason why the primary Payer did not pay the entire amount, aside from the Deductible, Co-Insurance and Copay. The reason code can be found on the primary payer's EOB.

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Some payers use their own set of reason codes to disallow payment, however electronic claims require all reason codes to be sent in a HIPAA-mandated format. A list of HIPAA approved reason codes can be found in the Internet Ability in MacPractice by clicking on Claims Adjustment Reason Codes in the sidebar or by visiting the WPC X12 website. If the payers are not using the HIPAA standard list, the payer specific list will need to be acquired.

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With the EOB columns turned on, the payer’s Internal Control Number or ICN can be entered in the last column.

Explanation of Claim Adjustment Group Codes

• CO - Contractual Obligations: This group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write-off for the provider and are not billed to the patient.

• CR - Corrections and Reversals: This group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim. When correcting a prior claim, CLP02 (claim status code) needs to be 22. See ASC X12N Health Care Claim Payment/Advice Implementation Guide (835) section 2.2.8 for complete information about corrections and reversals.

• OA - Other Adjustments: This group code should be used when no other group code applies to the adjustment.

• PI - Payer Initiated Reductions: This group code should be used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer, for example a medical review or professional review organization adjustments.

• PR - Patient Responsibility: This group should be used when the adjustments represent an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.

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