Purpose
The ERA Adjustment Reasons setup window is used in the Automated Payment Posting process. Once a claim has been ran through the Automated Payment Posting logic, the system will identify all Adjustment Reason Codes that are provided in the ERA/EOB. Each Adjustment Reason code will create a Payment/Adjustment record for the procedure line that the adjustment reason code is associated with. In some scenarios, the Adjustment Reason code provided may indicate that the claim was not posted cleanly and needs to be reviewed by a member of the billing team. If this is the case, a practice may choose to set a Claim Status or Claim Level override. A practice can customize these rules to meet the unique needs of the business.
Screen Layout and Definitions
Adjustment Reason Code List
The screen allows a user to change the workflow for each Adjustment Reason Code received. In the ERA, the Adjustment Reason Codes are provided in the 835 EDI FIle (Loop: 2110, Segment: CAS) by the payer. In the EOB, the Adjustment Reason Codes are usually listed procedure information.
In both the ERA and EOB, the Adjustment Reason Code is often paired with the Adjustment Group (CO, OA, PR, PI). You will notice that the system does allow for the Group to be specified. However, this is only necessary to configure if the code is treated differently because the group is included. For example, if a PR-22 and a PI-22 do the same thing, then you only need to setup the rules for a '22'.
Adjustment Reason Code Values
For each Adjustment Reason Code, the following can be specified:
- Group: An Adjustment Group can be added to an Adjustment Reason Code if it is necessary to treat the code differently because of the group.
- Denial Indicator: This flag indicates that this code/group combination is considered a denial reason. This will be utilized for reporting purposes.
- EOB Indicator: This flag indicates that this code will create an EOB record to send to the secondary insurance.
- Description: The description displayed can not be changed, but represents the description of the code as defined by the 835 standards.
Once the standard code details are configured, the Claim Status, Claim Level, and Payment types can also be configured. You will notice that you have the ability to modify these values for various Processing Levels.
- ERA Status: This is the Processing Level receiving on the ERA/EOB. In the ERA, the Processing Level is provided in the 835 EDI FIle (Loop: 2100, Segment: CLP02) by the payer. In the EOB, the Processing Level is usually listed with the information at the claim level.
- Claim Status: This value dictates that if the selected Adjustment Reason Code is received, the Claim Status will be overwritten and set to the value provided. If the 'Primary Claims' value is set, this will be treated as the Default for the other levels. If no value is set, the Claim Status will not be overwritten.
- Claim Level: This value dictates that if the selected Adjustment Reason Code is received, the Claim Level will be overwritten and set to the value provided. If the 'Primary Claims' value is set, this will be treated as the Default for the other levels. If no value is set, the Claim Level will not be overwritten.
- Payment Type: This value dictates which Payment Type is used for the corresponding Adjustment Amount provided with the Adjustment Reason Code. The 'Primary Claims' value must be set. This will be treated as the Default for all other other levels unless those levels are explicitly set. The Payment Type setup window will determine how that record affects the overall balance of the claim. Learn more here: Payment Type.
