1. Health Assets Management, Inc.465 BroadwayKingston, NY 12401P. (845) 334-3680F. (845) 340-7314 Understanding an Electronic Remittance Advice (ERA) Health Assets Management, Inc. 2011
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3. ERAs explain: the amount allowed by the insurance company (with respect to the charged amount), the amount paid by the insurance company, the amount deemed to be covered by another payer, and much, much more.
4. ERAs may be sent in place of, or in addition to, “standard” paper remittances that you may receive.Health Assets Management, Inc. 2011
11. Payment may say it’s from a larger insurance company, yet is actually from a smaller insurance company [i.e. AARP or UBH Optum “being paid” under the UHC umbrella.]Health Assets Management, Inc. 2011
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13. The check number shown on the ERA will correspond exactly with the number on the actual check. This is important for reconciling accounts.
14. The total amount of the check includes payment for all dates of service which are in the particular ERA. In this example, a $20.00 secondary insurance payment was made for one date of service.Health Assets Management, Inc. 2011
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16. This is not necessarily the location where services were performed, rather where the check is being sent.Health Assets Management, Inc. 2011
19. If an ERA contains more than one claim, the names will always be in alphabetical order by the patient’s last name.Health Assets Management, Inc. 2011
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21. The number may contain any combination of letters and/or numbers.Health Assets Management, Inc. 2011
24. There is no secondary insurance that the primary is aware of, in order to “auto-cross” the claim. This does not mean that the patient only has one insurance.Health Assets Management, Inc. 2011
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26. The primary insurance company is “auto-crossing” the claim to the secondary insurance company for processing.Health Assets Management, Inc. 2011
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28. Secondary insurance companies will not “auto-cross” claims to tertiary insurances, even if the patient has one.Health Assets Management, Inc. 2011
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30. You are being paid for this patient, for the services that you performed on this date.Health Assets Management, Inc. 2011
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32. Most common CPTs are 90801 (for the initial evaluation) and 90806 (for follow-up visits).Health Assets Management, Inc. 2011
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34. The higher the skill-level of the procedure, the higher the charged amount.
35. Insurance companies will decide exactly how much of the charged amount to “allow.”Health Assets Management, Inc. 2011
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37. This is the absolute maximum amount of money that the insurance companies (primary/ secondary/ tertiary), or the patient can be held responsible for.Health Assets Management, Inc. 2011
41. If the secondary and/or tertiary insurances do not cover this deductible amount, this amount should be expected directly from the patient.Health Assets Management, Inc. 2011
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43. If the patient only has one insurance, this amount should be expected directly from the patient.
44. Patient responsibility (without another insurance company covering the amounts) includes deductible and coinsurance.Health Assets Management, Inc. 2011
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46. The most common examples of adjustment reasons/amounts will be covered later in the presentation.Health Assets Management, Inc. 2011
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48. Payment always correlates directly with the charged amount, allowed amount, and any deductible/ coinsurance.Health Assets Management, Inc. 2011
51. For date of service 03/09/2011: $100.00 was charged, and the primary insurance company allowed $85.00. A payment of $85.00 (the full allowed amount) was made by the primary insurance.
52. There is no deductible, coinsurance, or patient responsibility.
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54. For date of service 03/22/2011: $100.00 was charged, and the primary insurance company allowed $100.00. A payment of $80.00 was made by the primary insurance, and a coinsurance of $20.00 should be billed to the secondary insurance.
55. This is the patient’s secondary insurance covering the balance which the primary had left over.
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57. For date of service 02/04/2011: $100.00 was charged, and the primary insurance company allowed $97.14. A payment of $44.86 was made by the primary insurance. $10.71 was applied to the patient’s deductible, and there is a coinsurance of $41.57.
58. A balance of $52.28 ($10.71 applied to deductible and $41.57 coinsurance) has been forwarded on to the secondary insurance.
59. This secondary insurance covered the amount applied to the deductible, as well as the coinsurance.
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61. For date of service 01/21/2011: $100.00 was charged, and the primary insurance allowed $97.14. There is no actual payment, but $66.78 was applied to the patient’s deductible and there is a coinsurance of $30.36.
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