On occasion, an AmeriHealth member?s specified cost-sharing (i.e.,
copayment, deductible, and coinsurance) may be greater than the
allowable amount for a service rendered during a visit. In this situation, only
the allowable amount for the service should be collected from the member. If
cost-sharing is collected and the provider or facility subsequently determines
that the allowable amount is less than the cost-share amount, the
difference between the cost-sharing collected and the allowable amount of the
service must be refunded to the member within a reasonable period (i.e., 45
days) at no charge to the member.
However, a member?s cost-share is applied per visit, not per claim
line. Accordingly, in a case where the member?s specified cost-sharing is
greater than the allowable amount for a service during a visit, but multiple
services are rendered during that visit that have an allowable amount that, in
the aggregate, is greater than the member?s specified cost-sharing, the member
cost-sharing should still be collected in full. The difference between the
applicable member cost-sharing due for the service and the lower allowable
amount for that service will be deducted from the additional services provided
during the visit.
There may be several different scenarios where these rules apply. The
following examples are provided for reference only:
Example 1
| Date(s)
of service | Procedure code | Provider charge | Our
allowance | Member
liability
(cost-sharing) | Provider
payment |
|---|
| 3/9/2018 | 99203 | $154.00 | $117.16 | $150.00 | $0.00 |
In this instance, the member liability is greater than
the allowable amount; therefore, the provider would only collect the allowable
amount of $117.16 from the member.
Example 2
| Date(s) of service | Procedure code
| Provider charge | Our allowance | Member
liability
(cost-sharing) | Provider
payment |
|---|
| 3/9/2018 | 99203 | $154.00 | $150.00 | $100.00 | $50.00 |
In this instance, the allowable amount is greater than the member
liability; therefore, the provider would collect the member liability of
$100.00 in full.
Example 3
| Date(s) of service | Procedure code | Provider charge | Our allowance
| Member liability
(cost-sharing) | Provider payment |
|---|
| 1 | 3/9/2018 | 99212 | $154.00 | $58.31 | $58.31 | $0.00 |
| 2 | 3/9/2018 | 20605 | $121.00 | $54.73 | $21.69 | $33.04 |
| 3 | 3/9/2018 | J3301 | $11.00 | $4.12 | $0.00 | $4.12 |
| Total | | | $286.00 | $117.16 | $80.00 | $37.16 |
In this instance, the member liability for the visit ? which is $80.00,
per benefits for the E&M code ? is more than the allowable amount ($58.31) for
the initial service line. However, since there were multiple services performed
during the same visit, the member?s cost-sharing is broken out and applied
separately to each service line until the total member cost-sharing is
satisfied. The full allowed amount of $58.31 is applied to the first service
line, and the balance of $21.69 is applied to the second line, totaling $80.00.
Since the total member cost-sharing has been satisfied, $0 is applied to the
third service line.
Questions?
If you have questions related to collecting member cost-share, please email
us at providercommunications@amerihealth.com.
Note: The Administrative Procedures section of the Provider Manual
for Participating Professional Providers and/or the Hospital Manual for
Participating Hospitals, Ancillary Facilities, and Ancillary Providers will
soon be updated to reflect the information outlined above.