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Sub-Field: 355.1411

Package: Integrated Billing

TYPE OF PLAN(#355.1)-->355.14-->355.141-->355.1411

Sub-Field: 355.1411


Information

Parent File Name Number Package
355.141 REASON CODE 355.1411 Integrated Billing

Details

Field # Name Loc Type Details
.01 REASON CODE 0;1 FREE TEXT
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X
  • LAST EDITED:  MAY 12, 2011
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  This is the Reason Code for which, when associated with the correct Group Code, this Type of Plan pays all or a percentage of the adjustments made to the original claim by the payer during adjudication. Example, if
    there is an entry of Reason Code 1 with the Group Code of PR, then this plan pays all or a percentage of the Patient's Deductable as indicated on the Medicare-equivalent Remittance Advice (MRA).
  • TECHNICAL DESCR:  If the claim's Type of Plan entry has an effective date on or before the claim service From date, the balance due for the secondary claim will be based on the patient responsibility multiplied by any percentages
    stored in the effective date multiple underneath the appropriate reason codes, plus excess charges if the Group Code CO is contained within this multiple and is associated with the correct Reason Code.
    UNEDITABLE
  • CROSS-REFERENCE:  355.1411^B
    1)= S ^IBE(355.1,DA(3),14,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)=""
    2)= K ^IBE(355.1,DA(3),14,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)
  • RECORD INDEXES:  AEDT (#987) (WHOLE FILE #355.14)
1 PART A PERCENTAGE 0;2 NUMBER
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  MAY 10, 2011
  • HELP-PROMPT:  Type a number between 0 and 100, 0 decimal digits.
  • DESCRIPTION:  This is the percentage (0-100) that this Type of Plan pays for PART A amounts returned under a Group and Reason code on an MRA. Example, if this plan pays 50% of the Part A Deductible, enter a Group Code of PR in
    the Group Code multiple, a Reason Code of 1 in the Reason Code multiple,
    and a 50 in this field.
  • TECHNICAL DESCR:  If the claim's type of plan entry has an effective date on or before the claim service date, the balance due for the secondary claim will be based on the patient responsibility multiplied by any percentages stored in
    the effective date multiple, plus excess charges if the Group Code CO is contained within this multiple and is associated with the correct Reason Code. Part A charges are calculated on Inpatient Institutional
    Claims.
    UNEDITABLE
  • RECORD INDEXES:  AEDT (#987) (WHOLE FILE #355.14)
2 PART B PERCENTAGE 0;3 NUMBER
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  MAY 10, 2011
  • HELP-PROMPT:  Type a number between 0 and 100, 0 decimal digits.
  • DESCRIPTION:  This is the percentage (0-100) that this plan pays for PART B amounts returned under a Group and Reason code on an MRA. Example, if this plan pays 75% of Part B Co-payments, enter a Group Code of PR in the Group
    Code multiple,a Reason Code of 2 in the Reason Code multiple, and a 75 in this field.
  • TECHNICAL DESCR:  If the claim's Type of Plan entry has an effective date on or before the claim service From date, the balance due for the secondary claim will be based on the patient responsibility multiplied by any percentages
    stored in the effective date multiple, plus excess changes if the Group Code of CO is contained within this multiple and is associated with the correct Reason Code. Part B charges are calculated on Outpatient
    Institutional claims and all Professional claims.
    UNEDITABLE
  • RECORD INDEXES:  AEDT (#987) (WHOLE FILE #355.14)
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