Entering Claim Adjustment Reason Codes

(Last Updated On: March 12, 2018)

If you have experienced your electronic secondary claims being denied on Emdeon Vision with the following message or one similar, you will need to start using Claim Adjustment Reason Codes going forward.

Message: Service Line COB Information: Invalid; the sum of all Service Line Paid Amounts plus the Service Line Adjustment Amounts for each payer must equal Line Item Charge Amount

How can you catch these errors before they go out the door?
In Practice Manager, click Administration > Transaction Tables > Insurance. Then open the appropriate Insurance. If you are sending secondary claims electronically, make sure to check “Requires Claim Adjustment information for Secondary Insurances”. If this is selected and you forget to enter a Claim Adjustment Reason, Practice Manager will remind you.

What are Claim Adjustment Reason Codes?
Claim Adjustment Reasons are the codes you find on an EOB explaining why the Primary Insurance paid as they did. Here are some examples:

CO 45- The Contractual Write Off
CO 253- Sequestration – reduction in federal payment
PR 1 – Patient Responsible due to deductible
PR 2 – Patient Responsible due to coinsurance
PR 3 – Patient Responsible due to copay
PR 96- Patient Responsible for a non-covered charge
For a complete list visit www.wpc-edi.com\codes.
The Good News:
If you are using ChartMaker© Practice Manager Auto Payment Posting this information is automatically entered for you.

If you are not using Auto Payment Posting or have a few payments that need to be entered manually, no worries – we have you covered! When posting a primary insurance payment or write off manually that will then bill out electronically to a secondary payer, you can enter the Claim Adjustment Reason(s) while entering the primary payment and write off. To do this:

1 In Practice Manager, go to the Payment tab

2. In the Make a Payment sub-tab, enter the primary insurance payment information including the Allowed and Write Off amounts

3. Click the “More” button

4. Practice Manager will fill in the first Claim Adjustment Reason for you by pulling it from the payment information you entered. Click “Add To List”

Enter your next Claim Adjustment Reason and click “Add To List”

When the Amount Remaining is zero and you have accounted for all of the remaining money and added all of the necessary codes, click “Close”

NOTE: It is possible to have more than 2 Claim Adjustment Reason Codes. In the following example we have four:

CO 45 – Write Off due to Contractual Obligation

CO 253 – Write Off due to Sequestration – reduction in federal payment

PR 1 – Patient Responsible due to deductible

PR 2 – Patient Responsible due to coinsurance
Once the Claim Adjustment Reasons are entered you can always find the information in the Inquire tab. Go to the Inquire tab and click the Payment sub-tab. Then, on the right under View, select the radio button for “Claim Adj”.