Posting Insurance Payments

If, in the Payment Entry Lead-in screen, you typed a payment code that is assigned as an Insurance Payment, all payments posted with this code are deducted from the insurance balance.

You can review how your payment codes are set up in Review Payment Codes or edit them in Maintain Payment Codes.

You do not have the option to apply payments on an oldest charge basis if the payment code you selected is for an insurance payment.

To start allocating the insurance payment, you must click in the Allow (Allowed Amount) field of the line item you want to pay. If the payment is an insurance payment from the primary carrier and that carrier has a Fee Schedule, the allowed amount contained in the Fee Schedule for the procedure selected will be displayed, or the field will contain the full amount of the charge. If the allowed amount is correct, you may accept the response by pressing TAB, otherwise type the correct amount and press TAB.

You may also update the allowed amount in the Fee Schedule linked to the primary carrier, by typing the correct amount immediately followed by an "*".

For example, the allowed amount first displayed 100.00 but you can type 200.00*. Doing so will immediately store the corrected allowed amount for that procedure in the appropriate Fee Schedule, even if you were to click Cancel and abandon payment entry. Press TAB to proceed with posting the payment.

The pointer will move to the Payment field next. The default payment amount takes into consideration the allowed amount and the amount stored in the Insurance Liability field contained in the patient's Insurance Information. Note: Medicare payments for laboratory fees will default to 100 percent of the allowed amount regardless of the insurance liability. You may press TAB to accept the default amount displayed or type the correct payment amount and press TAB.

After the payment amount has been accepted, the pointer will advance to either the Adjust or Deny field. If an adjustment code was selected in the payment entry screen, the pointer will move to the Adjust field, otherwise it will move to the Deny field. If an allowed amount does not exist for the procedure being paid, the pointer will automatically stop at the Adjust column allowing you to enter an adjustment amount. If Accept Assignment is N for this procedure, the adjustment will not be automatically calculated.

If you have a fee schedule tied to the patient's insurance carrier and the procedure allowed amount is less than the original charge amount and you are accepting assignment on the individual charge, a default amount will be displayed in the Adjust field. This amount will be the difference between the original charge and the allowed amount. You may press TAB to accept the default amount displayed or type the correct adjustment amount.

After the adjustment amount has been accepted, the pointer will advance to the Deny field. If an amount is entered in the Deny field, the Deny dialog box displays so you can select a practice denial reason from the Practice Denial Code Table and an ANSI CARC/RARC code from the ANSI CARC/RARC table. If you click Cancel, the amount in the Deny field clears so you can either type a new amount or move to the next line item.

If a denial is entered, the final display on this screen may look a little peculiar and/or inaccurate. The display on this screen simply reacts to the information that is entered with no consideration to what the actual circumstances of the procedure may be (i.e., patient has primary and secondary insurance and the primary denies the claim, this screen display will immediately move the denial amount from the insurance balance column into the patient balance column without accounting for the existence of the secondary insurance.

When the payment is actually saved, the system does all of the routine checks to determine what the patient and insurance balances should be. Only until this time can you be sure that the insurance and patient balances are correct. Generally, if an insurance payment or denial is entered, the balance on that line item will move from insurance liability to patient responsibility. However, if the insurance payment is from the patient's primary insurance carrier, or a denial was entered from the primary carrier, and the patient has a secondary carrier, the balance on that line item will be moved back to the insurance balance. If the liability entered for the patient's secondary carrier is set to zero (See Patient Change - Insurance), then the balance owing will remain in patient responsibility.

There are times, however, where you might want to override the automatic shift of balances. You may, for example, receive a partial payment from the patient's primary insurance and not want a secondary claim generated until you receive the entire payment. Or, you may want to force the balance to the patient's responsibility for a line item even though they have a secondary carrier. See Payment Actions for instructions on shifting balances.

Each time an amount is entered on a transaction line, the appropriate totals are immediately updated in the top section of the screen. For example, the paid amount updates the balance due, payment remaining and amount allocated. The adjust amount updates the balance due and adjustment amount total and the deny amount updates the denial amount total.

The pointer will continue to drop down to the next transaction line until the Payment Remaining field contains zero (0.00), or until you click Save. If you do not allocate the entire payment entered, a message box will pop up that informs you that you have left part or all of the payment unallocated and asks Do you want to post this payment? You can click Cancel if you do not want to leave part of this payment unallocated and want to continue applying the payment, or you can click OK to save this payment.

NOTE - Secondary claims sent electronically: When the payment for the primary insurance carrier is posted, if the allowed amount is not entered or is bypassed and entered with the same amount as the billed amount, the program will automatically calculate the allowed amount to be included on the secondary claim. This change should prevent the secondary insurance carrier from overpaying the claim and compensate for when the allowed amount is not entered correctly.