Introduction

(music)

Judy: Hello. I’m Judy the Numbers Juggler, here today with Simon the robot (Simon: Compliance!) to talk about TPL numbers.

Edit 165

Judy: Simon, what’s the significance of the number 165?

Simon: That information is not available.

Judy: Sure it is! Edit 165 is the code you might see on your denied TPL claim.

Simon: What is the function of Edit 165?

Judy: Well, it tells us that TPL claims require you to enter a “patient responsibility” amount – even if it’s zero.

Field 30

Simon: Which field on the claim denotes the patient responsibility?

Judy: Another TPL number, Simon, the number 30! For the CMS-1500, the patient responsibility amount goes in field 30. Make sure that field is filled with something, even if the amount is zero.

Simon: What about for electronic users like myself?

Judy: Depending on what tool you use, just make sure you enter something in these three fields: deductible, coinsurance, and copayment.

Simon: Equation: deductible plus coinsurance plus copayment equals “patient responsibility.”

Judy: A good equation to remember!

Medicaid Calculation

Judy: Simon, do you know why the patient responsibility amount is so important?

Simon: That rationale does not yet compute.

Judy: It’s because Medicaid needs that information to figure out the provider payment.

Simon: Need more input.

Judy: Medicaid takes the patient responsibility amount and compares it with the Medicaid Allowed Amount after all other carriers' paid amounts have come out.

Simon: Which amount does Medicaid pay the provider?

Judy: The lesser of the two. So, Simon, let me give you a math problem to solve.

Simon: My circuits are specially wired for mathematics.

Judy: I know. Let’s say the patient responsibility amount is $25. And let’s say Medicaid’s allowed amount for that service was $500. The third party carrier already paid $400. So, how much will the Medicaid payment be?

Simon: (computing sounds) $500 Medicaid allowed minus $400 third party carrier payment equals = $100. $100 dollars is greater than the $25 patient responsibility. Medicaid will pay the lesser of the two: $25.

Judy: Right on!

Payment in Full

Simon: Is this computation 100% reliable?

Judy: One caveat: The provider may have agreed to accept “payment in full” from the third party payer, including Medicare. If that’s the case, the third party payment plus the “patient responsibility” cannot exceed the agreed-to amount.

Emphasize Required Field

Simon: All these rules are beginning to overload my database.

Judy: Point taken, Simon. If you don’t remember anything else, just be sure to enter the patient responsibility amount. It’s required for TPL claim payment. And it’ll keep you from getting edit code 165 on your remit. Also, you can check out the attached podcast links for reference guides.

Simon: Data loaded and saved.

Closing

Judy: Very good! Simon, go get us some lunch.

Simon: Compliance!

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