Billing EOB/Denials Tab

The EOB/Denials tab lists all insurance payments that have been posted on the visit. The child tabs allow the user to view, add, update, and delete denial codes and create payment and denial overrides. This is used to bill secondary claims properly. The tabs allow you to work with claim-level denials (typically for inpatient claims) and service line denials (typically for outpatient claims).

Explanation of Benefits – Payment Override

The Explanation of Benefits – Payment Override tab is used to add payment or payment date override information in order to balance the account. The EOB Balance column is updated according to the payment added in this tab and claim or service line overrides added in other child tabs. The goal is to reduce the balance to zero.

To add a payment override, follow these steps:

1. Select a payment in the EOB/Denials parent tab.
2. Click the Add button . A row is added to the EOB – Payment Override list, the primary insurance’s payment information is imported to the Pay Amt and Pay Date fields, the EOB Balance column is updated, and the entry fields are enabled.

3. Destination Insurance – Click the dropdown and select the insurance. All insurances associated with the visit are listed and numbered by rank.
4. Pay Amt – Enter the payment override amount. This amount can be greater than the balance, if needed.
5. Pay Date – Click the field to enter the date directly or click to select a date from a calendar.

6. Click Save.

Claim Denial

The Claim Denial tab displays any claim denials posted with the selected payment. This read-only information can be used as a reference when attempting to override data for secondary billing.

Explanation of Benefits Override – Claim Denial

The Explanation of Benefits Override – Claim Denial tab is used to add or update claim-level denial code information for the secondary claim.

To add a claim denial override, follow these steps:

1. Select a payment in the EOB/Denials parent tab.
2. Click the Add button . A row is added to the EOB Override – Claim Denial list, and the entry fields are enabled.

3. Destination Insurance – Click the dropdown and select the insurance. All insurances associated with the visit are listed and numbered by rank. The Load Claim Data button is enabled.

4. At this point, you can choose one of two options or mix them:
   • Load Claim Data – Click the button to load denial information that was posted with the secondary claim that was denied. Denial information can then be updated.

• • Manually enter the denial information:
  • CAS Group Cd – Enter the CAS Group code. The group code used to identify who is financially responsible for the amount that the payer is not reimbursing.
  • CAS Reason Cd – Enter a CAS reason code in the first field or a CAS reason description in the autocomplete field (clicking a suggested description to select it).
  • Quantity – Enter the quantity.
  • Amount – Enter the denial amount.

6. Click Save.

Service Line Detail/Denials

The Service Line Detail/Denials tab displays any service-level denials posted with the selected payment. This read-only information can be used as a reference when attempting to override data for secondary billing.

The list shows each service line and its information, which includes the charge date, revenue ID, HCPCS code, quantity, charge amount, and paid amount. Click the + to expand and view the specific service line denial information, which includes the group, denial code and description, quantity, and denial amount.

Explanation of Benefits Override – Service Line Detail/Denials

The Explanation of Benefits Override – Service Line Detail/Denials tab is used to add or update service-level charge and denial code information for the secondary claim. For example, the primary and secondary insurances may have different HCPCS claim codes for charges or different CAS Reason Codes that need to be updated before rebilling the visit. This is most likely to be used for an outpatient visit.

The Line Balance column displays the charge amount less the payment and denials amounts. It should equal zero. Service lines where these amounts do not equal zero will need to be corrected.

To add a service line denial override, follow these steps:

1. Select a payment in the EOB/Denials parent tab.
2. Click the Add button . A row is added to the EOB Override – Service Line Detail/Denials list, and the entry fields are enabled.

3. Destination Insurance – Click the dropdown and select the insurance. All insurances associated with the visit are listed and numbered by rank. The Load Claim Data button is enabled.

4. At this point, you can choose one of two options or mix them:
   • Load Claim Data – Click the button to load into the list denial information from the secondary claim that was rejected. Date, revenue code, HCPCS code, quantity, charge amount, paid amount, NDC number, or physician NPI can then be updated along with the denial information.

• • Manually enter the charge information:
  • Date – Click the field to enter the date directly or click to select a date from a calendar.
  • Rev Cd – Enter the revenue code.
  • Hcpcs – Enter the HCPCS code and any modifiers.
  • Quantity – Enter the quantity.
  • Charge Amt – Enter the charge amount.
  • Paid Amt – Enter the amount paid by the primary insurance.
  • NDC No – Enter the NDC (National Drug Code) number.
  • Phys. NPI – Enter the physician’s NPI number.

5. Click the Denial Info button. Add or update loaded denial info.
6. Click Save.

Denial Info

The Denial Info window is used to add or update service-level denial code information for the secondary claim. If the user clicked the Load Claim Data button on the Explanation of Benefits Override – Service Line Detail/Denials tab, the denials will display and can be updated.

To add a service line denial, follow these steps:

1. Click on a service line in the Explanation of Benefits Override – Service Line Detail/Denials tab to select it.
2. Click the Add button . A row is added to the Denial Information list, and the entry fields are enabled.

3. CAS Group Cd – Enter the CAS Group code. The group code used to identify who is financially responsible for the amount that the payer is not reimbursing.
4. CAS Reason Cd – Enter a CAS reason code in the first field or a CAS reason description in the autocomplete field (clicking a suggested description to select it).
5. Quantity – Enter the quantity.
6. Amount – Enter the denial amount.

7. Click Save.