EOMB Codes

The EOMB (Explanation of Medical Benefits) codes record the reason(s) a claim, invoice or charge is rejected or adjusted by an insurer. EOMB codes can adjust an entire invoice or a line on an invoice. Since a variety of coding systems are used by insurers in different areas, you must add the codes you need.

The description will probably be abbreviated in the Description field on the EOMB screen as it only holds 40 characters. Complete details can be stored in the F3 memo.

File Maintenance > Setup - Billing > EOMB codes

EOMB codes

If you plan to use SYSTOC_EDI for billing secondary payers (aka coordination of benefits), the Claim Adjustment Group and Reason Codes must be on the same line item for both adjustments and balances on the Receipts and Adjustments Pay Charges screen.

To ensure that your EOMB codes are included in SYSTOC_EDI, the ID field must be entered in the following manner, <Group code><Reason code>.

You may find it helpful to include an abbreviated description of both the group and reason codes separated by a comma in the Description field.

ID Description
CO45

Contractual, Exceeds allowable

PR2

Patient responsibility, Coinsurance

PR1

Patient responsibility, Deductible

To prepare for the data entry, we recommend that you review EOMBs that you received over the past few months to determine your most common group and reason code combinations.

For a complete list of codes see http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment- reason-codes/.