The claim level Coordination of Benefits (COB) information displays here. This information is used to indicate the total monetary amount reported. When a user enters the Payer Name in the payer section, the name displays on the accordion banner for each payer type (primary, secondary, tertiary).
The COB fields are defined below (gray fields are disabled):
Payer Information (Primary, Secondary, and Tertiary Payer)
The Health Plan responsible for payment.
Subscriber NameSubscriber Name
The person identified as the holder of the Health Plan policy.
Payer Paid AmountPayer Paid Amount
Dollar amount paid by the provider.
The date of the payment by the Health Plan.
The order in which the Health Plan is responsible for payment - first, second, or third, usually labeled primary, secondary, or tertiary.
Total Claim ChargesTotal Claim Charges
The total of all procedures charged on the claim.
Total Non-Covered AmountTotal Non-Covered Amount
Dollar amount not covered by the payer and excluded for payment.
Outbound Payer CodeOutbound Payer Code
The payer code which identifies the Destination Health Plan. If the inbound payer code is not valid, eMEDIX will route to the correct outbound payer code.
Adjustment BalanceAdjustment Balance
The sum of all the adjustments.
Remaining Patient Liability Remaining Patient Liability
Dollar amount that the patient is responsible to pay after all the payers have paid.
Medicare Outpatient Adjudication
Reimbursement RateReimbursement Rate
Reimbursement rate percentage expressed as a decimal. Required when returned in the remittance advice.
Non-Payable Prof Component AmountNon-Payable Prof Component Amount
The professional component amount billed but not payable. Required when returned in the remittance advice.
Claim HCPCS PayableClaim HCPCS Payable
The claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Required when returned in the remittance advice.
Claim ESRD PaymentClaim ESRD Payment
The End State Renal Disease (ESRD) payment amount. Required when returned in the remittance advice.
Used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC), or to convey information about remittance processing.
Claim Level Adjustment Information
Code identifying the general category of payment adjustment. Options are:
| CO | Contractual Obligations |
| CR | Correction and Reversals |
| OA | Other Adjustments |
| PI | Payer Initiated Reductions |
| PR | Patient Responsibility |
Code Identifying the detailed reason for the adjustment. Up to five (5) reason codes can be added.
The amount of the adjustment.
The unit of service being adjusted. Required when the number of service units has been adjusted.
Add Claim Level Adjustment InformationAdd Claim Level Adjustment Information (button)
Click to add another claim level adjustment. Up to five (5) adjustments can be added.
When a user enters the Payer Name in the payer section, the name displays on the accordion banner for each payer type (primary, secondary, tertiary).
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