Enter Three or More EOMB Codes Per Line Item

In this scenario, the insurance company paid a portion of the office visit. The EOMB indicated multiple adjustments because the fee schedule maximum allowable was exceeded and a prompt pay discount was applied. The remainder is the patient responsibility.

Note: Extra steps are required when there are two or more EOMB adjustment codes, either with the same or different group code. Add a separate line for each additional adjustment code. Enter the adjustment or denial reason code in EOMB and leave EOMB2 blank until the last code for the line item has been entered.
Example:
  • Total OV charge: $152.14
  • Primary insurance paid: $75.00 (EOMB CO45 - Charge Exceeds Fee Schedule Maximum Allowable by $25.00)
  • Primary insurance discount: $15.00 (EOMB CO44 - Prompt Pay Discount)
  • Patient responsible for balance $37.14
  • The payment of $75.00 and the first adjustment of $25.00 will be applied first

These steps presume that SYSTOC and SYSTOC_EDI settings are correct before EOMB codes are applied. It is also presumed that the primary and secondary insurance information and the relationship to the subscriber have been documented, as well as the relationship to the patient if there is an alternate subscriber.

  1. Navigate to Billing Folder > Receipts/Adjustments.
  2. Click the Insurance radio button. Browse and select the appropriate insurance plan from the Payment from Ins Plan ID lookup.

  3. Click Continue to Invoice Search.
    The Search for Invoices screen displays.
  4. Search for the correct invoice using the normal SYSTOC procedure.
  5. Click Next to Pay Charges.
    The Pay Charges screen displays. The payment, adjustment, and remaining balance for each line item must equal the total line item charge. The claim will be rejected if payments and adjustments do not equal the total charge on the 837 claim file.

  6. Click Commit.
    The Invoices with Balances screen displays.

  7. Click Cancel. The Check Information screen displays. Leave the check amount at 0.00 since no additional payment has been received and additional EOMB adjustments must be entered.

    Another adjustment from the primary payer must be applied before moving the claim to the next responsible party.
  8. Click Continue to Invoice Search.
    A warning displays that the check amount is zero.

  9. Click No.
  10. Click Next to Pay Charges.
  11. Click Continue to Invoice Search.
    The Search for Invoices screen displays.
  12. Search for the correct invoice using the normal SYSTOC procedure.
    The Search for Invoices screen does not display the payment and adjustment just applied because it has not yet been reconciled.

  13. Click Next to Pay Charges. The Pay charges screen displays.
    (The payment of $75.00 and an adjustment of CO45 for $25 was applied previously.)
  14. Enter the EOMB code of CO44 for $15.00.
  15. Enter the PR1 code in EOMB2. The patient is now responsible for the remaining balance of $37.14.

  16. Click Commit.
    The Invoices with Balances screen displays.

  17. Select the next responsible party or secondary insurance from the drop-down list.
  18. Click Commit to complete the data entry.
    The claim transmits to the secondary payer when processed.