http://www.healthassets.com/

1. Health Assets Management, Inc.465 BroadwayKingston, NY 12401P. (845) 334-3680F. (845) 340-7314 Understanding an Electronic Remittance Advice (ERA) Health Assets Management, Inc. 2011

3. ERAs explain: the amount allowed by the insurance company (with respect to the charged amount), the amount paid by the insurance company, the amount deemed to be covered by another payer, and much, much more.

4. ERAs may be sent in place of, or in addition to, “standard” paper remittances that you may receive.Health Assets Management, Inc. 2011

5. What does this mean? Health Assets Management, Inc. 2011

7. Patient and Insurance Payment Information

8. Adjustment Code ExplanationsHealth Assets Management, Inc. 2011

9. Insurance Company, Check, and Pay-To (Provider) Information Health Assets Management, Inc. 2011

11. Payment may say it’s from a larger insurance company, yet is actually from a smaller insurance company [i.e. AARP or UBH Optum “being paid” under the UHC umbrella.]Health Assets Management, Inc. 2011

13. The check number shown on the ERA will correspond exactly with the number on the actual check. This is important for reconciling accounts.

14. The total amount of the check includes payment for all dates of service which are in the particular ERA. In this example, a $20.00 secondary insurance payment was made for one date of service.Health Assets Management, Inc. 2011

16. This is not necessarily the location where services were performed, rather where the check is being sent.Health Assets Management, Inc. 2011

17. Patient and Insurance Payment Information Health Assets Management, Inc. 2011

19. If an ERA contains more than one claim, the names will always be in alphabetical order by the patient’s last name.Health Assets Management, Inc. 2011

21. The number may contain any combination of letters and/or numbers.Health Assets Management, Inc. 2011

22. Claim Status Health Assets Management, Inc. 2011

24. There is no secondary insurance that the primary is aware of, in order to “auto-cross” the claim. This does not mean that the patient only has one insurance.Health Assets Management, Inc. 2011

26. The primary insurance company is “auto-crossing” the claim to the secondary insurance company for processing.Health Assets Management, Inc. 2011

28. Secondary insurance companies will not “auto-cross” claims to tertiary insurances, even if the patient has one.Health Assets Management, Inc. 2011

30. You are being paid for this patient, for the services that you performed on this date.Health Assets Management, Inc. 2011

32. Most common CPTs are 90801 (for the initial evaluation) and 90806 (for follow-up visits).Health Assets Management, Inc. 2011

34. The higher the skill-level of the procedure, the higher the charged amount.

35. Insurance companies will decide exactly how much of the charged amount to “allow.”Health Assets Management, Inc. 2011

37. This is the absolute maximum amount of money that the insurance companies (primary/ secondary/ tertiary), or the patient can be held responsible for.Health Assets Management, Inc. 2011

39. Some secondary insurances will cover the deductible, but others will not.

40. Secondary insurances can have a deductible as well.

41. If the secondary and/or tertiary insurances do not cover this deductible amount, this amount should be expected directly from the patient.Health Assets Management, Inc. 2011

43. If the patient only has one insurance, this amount should be expected directly from the patient.

44. Patient responsibility (without another insurance company covering the amounts) includes deductible and coinsurance.Health Assets Management, Inc. 2011

46. The most common examples of adjustment reasons/amounts will be covered later in the presentation.Health Assets Management, Inc. 2011

48. Payment always correlates directly with the charged amount, allowed amount, and any deductible/ coinsurance.Health Assets Management, Inc. 2011

49. Real World Examples Health Assets Management, Inc. 2011

51. For date of service 03/09/2011: $100.00 was charged, and the primary insurance company allowed $85.00. A payment of $85.00 (the full allowed amount) was made by the primary insurance.

52. There is no deductible, coinsurance, or patient responsibility.

54. For date of service 03/22/2011: $100.00 was charged, and the primary insurance company allowed $100.00. A payment of $80.00 was made by the primary insurance, and a coinsurance of $20.00 should be billed to the secondary insurance.

55. This is the patient’s secondary insurance covering the balance which the primary had left over.

57. For date of service 02/04/2011: $100.00 was charged, and the primary insurance company allowed $97.14. A payment of $44.86 was made by the primary insurance. $10.71 was applied to the patient’s deductible, and there is a coinsurance of $41.57.

58. A balance of $52.28 ($10.71 applied to deductible and $41.57 coinsurance) has been forwarded on to the secondary insurance.

59. This secondary insurance covered the amount applied to the deductible, as well as the coinsurance.

61. For date of service 01/21/2011: $100.00 was charged, and the primary insurance allowed $97.14. There is no actual payment, but $66.78 was applied to the patient’s deductible and there is a coinsurance of $30.36.

64. The most common of all adjustment codes.

65. Charged Amount - Adjusted Amount = Allowed Amount Health Assets Management, Inc. 2011

67. This is how much the previous payer was responsible for.Health Assets Management, Inc. 2011

69. This insurance company will not cover this procedure code. This amount is direct patient responsibility.Health Assets Management, Inc. 2011

71. Health Assets Management, Inc. 465 Broadway Kingston, NY 12401 P. (845) 334-3680 F. (845) 340-7314 Health Assets Management, Inc. 2011