Payment Work/ Job Profile: I was posting payment through EOB.
EOB we were using for For
manual posting and ERA for Auto posting.
Patient Responsibility – those are responsibility pay by patient to provider
Deductible (PR1): It is a fixed amount which is paid by patient to the provider on annual basis only
then after insurance company start giving benefit to the patient.
Co-insurance (PR2): It is specified (%) percentage of Allowed amount which is paid by patient or
secondary Ins to the provider.
Copay (PR3): It is a small dollar amount which is paid by the patient to provider on every visit. It is a
just like doctor fee
WO or Offset: When an insurance Make over payment in previous claim, that
amount Will adjust in the next EOB That is called Offset
Re-fund: When an insurance company make over payment, they take back that
amount is called refund.
Recoupment: When an insurance company process incorrectly EOB, then they
take back the entire payment, is called the recoupment
Medicare Insurance: It is Nation government insurance and to get the Medicare insurance
there are three eligibility criteria.
1st 65 years old or above.
2nd suffering from end stage renal disease (ESRD) . Kidney Faliure
3rd Permanent disability.
Medicaid insurance: It is a state government insurance for low-income group. Medicaid is
always last payer. PATEINT NEVER PAY ANY AMOUNT
Interest payment (L6) -when insurance company make a late payment to
provider called the interest payment charges
CO253 (Sequestration adjustment): It is a 2% of Medicare payment reduction and it kinds
of adjustment.
CO 45: Contractual adjustment Diffence amount b/w billed and allowed
amount
EOB: Explanation of Benefits): - This is a document that is sent by insurance company to the
provider which contains all the payment posting and Denial detail.
ERA: Electronic Remittance Advice): It is digital form of the EOB and it is use for auto posting
Billed amount, allowed amount, paid amount, copay, deduction, co-insurance CPT DOS adjustment amount
(CO45, CO253). Patient detail and insurance company detail, etc.
EOB- Goes to Patient as well as Provider
EOB -It is used for Mannual Posting
EOB-PDF Form
ERA-Only to Provider
ERA-It is used for Auto Posting
ERA- Digital form
COPAY, DEDUTABLE, COSINRUANCE**offset refund , overpayment recovery,
interest payment L6
Inpatient – A person who Admitted more than
24 hours
Outpatient- A person who Admitted Less than
24 hours
POS-Ii is a location where doctor give the
treatment
11-Office
12-Home
21-Inpatient
22-Outpatient
23- Emergency
Modifier- It is two digit nueric and Alpha
numeric code which enhance the value of CPT
26= Professional Services
25-E&M
59-Sepearte servicew given by doctor on same
day
76- Repeat procedure by same doctor on same
day
77- Repeat procedure by Differnet doctor on
same day
LT- Left side
RT-right Side
NPI-National provoder Identifier it is 10 digit
numeric which is issued by CMS and it is Kind of
Lisence number
Tax ID-It is 9 digit code which is use for
taxation purpose
SSN-It is 9 digit nuber which is used by govt to
track the earining of US citizen (PAN Card)
HIPAA-Health ins portability and accountability
act which was establish on 21- aug-1996 which
helps to procted the patient Health info
COBRA-It is a plan when patient loss his job
then he can use cobra for 18 month.
CPT-Current procedure Terminology and it of 5
digit and use for Treatment code
Dx (ICD)- it is of 3-7 digit code which shows
illness/Disease
HMO In-intetwork benefits
Cheaper plan
PCP requirement ( referral required )
(In this plan, the patient can visit the only in-network healthcare provider. To visit a
specialist patient, need to take referral number from Primary care physician (PCP is a
general
doctor who is not a specialist).
Taking a referral number from PCP is patient responsibility)
PPO In-network and out of network
Expensive plan
no referral required
(In this plan, the patient can visit an innetwork provider as well as out of
network provider. The patient can directly visit a specialist)
Ins Name-Aetna,Cigna,BCBS,Humana, UMR,UHC, Molina,
( Blue cros blue shield)
Target 750-800 one number
Process- Dignity Health
Software-Invision
Process Of Payment Posting
We got Work From Our Team Lead through Email In which batch # were There
Then I have to create a batch ( Chk#, Chk date ,Chk amount)
After the We have to enter The claim ID from the EOB
Before posting the payment we have to confirm the Patient detail.
If Its correct then we will post the payment.
If we found any payment is posted incorrectly so we have to verify from EOB and
We have to post the payment correctly.
This is all about my work
