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 the RA. 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 United Health Plan, which 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.

1. What is the name of Karen Giroux’s secondary insurance plan?

2. Based on the RA, how much has Karen Giroux paid up to now toward her 2016 deductible? How much of her deductible is due with this claim? Once she pays this amount, what percentage of her claims will be covered by Aetna?

3. What amount does Karen Giroux owe for procedure 99386?

4. United Health Plan has paid Dr. Ronkowski $104 for Karen Giroux’s claim. How was this amount calculated?

5. What percentage of the eligible charge has United Health Plan paid for Jean Ruff’s claim? Based on the RA, has she met her $250 deductible?

6. What amount does Jean Ruff owe for procedure 99202? What percentage of the eligible charge does this equal?

FIGURE 16.4 RA from Payer

7. Suppose Jean Ruff had not met any portion of her deductible and was responsible for the full eligible amount of procedure 99202, $75. Would it still be necessary to send a secondary claim?

8. Based on the RA, calculate how much each patient is responsible for on the primary claim. Then estimate how much you think each secondary payer will pay. Note the following:

▶ The guarantor for Karen Giroux’s secondary coverage, her husband Jack, has met his Medicare Part B deductible.

▶ Jean Ruff’s secondary coverage, provided through her husband’s plan, pays for 100 percent of covered services and has a $15 copay.

	Patient resp.	Estimated amount from
Patient	on primary claim	secondary payer
Giroux, K.	_____________	_____Medicare Nationwide
Ruff, J.	_____________	_____Aetna Choice

Preparing Secondary Claims

Using the information shown in the United Health Plan RA ( Figure 16.4 ), pre-pare secondary claims for both United Health Plan patients. You will need to base the secondary claims on the primary claims you created for each patient in Chapter 15.

   

Secondary claim	Patient	Primary claim
Claim Case Study 16.4A	Giroux, K.	Claim Case Study 15.17 (p. 519)
Claim Case Study 16.4B	Ruff, J.	Claim Case Study 15.18 (p. 520)

 

 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 United Health Plan, which 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.

UNITED HEALTH PLAN 123 West Main Street Cleveland, OH 44101 PROVIDER REMITTANCE Pag: 1 of 2 VALLEY ASSOCIATES, PC 1400 West Center Street Toledo, CH 43601 Date: 10/14/2016 ID # 23AAY20 Charge Eligible Deduct Proc Oty amount amount Copay Patient Amtpaid Fablity provider Dates of service From - thru POS PROVIDER Naroy Rorkowsk, ND CLAM 2383876 Paterts name: Giroux, Karen 1008/16 - 1006/16 11 98386 1 $ 180.00 $ 180.00 $ 50.00 due $26.00 $104.00 CLAMINFCRMATION FORWARDEO TO MEDICARE NATIONMMIDE PROVIDER Chiskoher Cornly, D CLAM 2383882 Patent's name: Auft, Jean 1004/16 - 1004/16 11 99202 1 $75.00 $75.00 $15.00 $60.00 CLAMINFOAMATION FORWARDED TO. AETNA CHCICE