Posting Logic for Bundled and Unbundled Payments
You can post bundled and unbundled ERA payments for professional or institutional claims. Bundled payments are single ERA payments remitted for multiple charge lines. Unbundled payments are multiple ERA payments remitted for a single charge line with a quantity greater than one.
The following table describes the various settings and their results for an ERA file.
| Encounter Charge | Remittance Profile Library Setting | ERA File | Result | ||
|---|---|---|---|---|---|
| Claim | REF*6R Segment | SVC Segment | |||
| Single charge, Quantity >1 | Single line, Quantity >1 | Enable Post Unbundled Payment to Single Charge | Present | Unbundled payment (an individual payment per unit) | The system posts the allowed amount, payment and adjustment amounts against the single charge using REF*6R and adds the individual transactions as one. |
| Single charge, quantity >1 Another single charge where quantity = 1 | First line with quantity >1 Second line with quantity = 1 | Enable Post Unbundled Payment to Single Charge | Present | Unbundled payment for charges with quantity >1 Another payment for the charge where quantity = 1 | The system posts the allowed amount, payment and adjustment amounts against the single charge where the quantity is greater than 1, and the transactions for the charges where quantity is equal to 1, are posted based on the REF*6R. |
| Single charge, Quantity >1 | Single line, Quantity >1 | Enable Post Unbundled Payment to Single Charge | Absent | Unbundled payments (an individual payment per unit) | The system posts the transactions for charges where the quantity is greater than 1, based on Date Of Service (DOS), CPT® code and the number of units billed against the charge line. |
Single charge, quantity >1. Another Single charge where quantity = 1. | First line with quantity >1 Second line with quantity = 1 | Enable Post Unbundled Payment to Single Charge | Absent | Unbundled payments for charge with quantity >1 Another payment for charges where quantity = 1 | The system posts the transactions for the charges where the quantity is greater than 1, based on DOS, CPT code, and the number of units billed against the charge line. The transactions for the charge where the quantity is equal to 1, are posted based on the REF*6R. |
| Individual charges for the same CPT code | One line with quantity > 1 |
Enable the following:
| Present | Bundled payment for all charges with the same CPT code | The system matches to charges using DOS, CPT code, and quantity. When the charges are identified, the allowed, payment, and adjustment amounts are divided by the quantity and posted equally to the charge lines. Patient-responsible amounts for deductible (PR1) co-insurance (PR2) and copay (PR3) are distributed equally only for reporting and Coordination of Benefits (COB) balancing. Adjustments are not created for patient-responsible amounts. |
| Individual charges for the same CPT code and an additional charge for another CPT code. All quantity = 1 | One line with quantity > 1 and another line with quantity =1 |
Enable the following:
| Present | Bundled payment for all charges with the same CPT, quantity >1 and a separate payment for the charge where quantity is = 1 | The system matches charges by DOS, CPT code, and quantity. When the charges are identified, the allowed, payment, and adjustment amounts are divided by the quantity and posted to the charge lines equally. Line-item posting logic is used for the single line with a different CPT code. Patient-responsible amounts for deductible (PR1) co-insurance (PR2) and copay (PR3) are distributed equally only for reporting and COB balancing. Adjustments are not created for patient-responsible amounts. |
| Individual charges for the same CPT code | One line with quantity > 1 | Enable Post Bundled Payment to Multiple Charges | Absent | Bundled payment for all charges with the same CPT code and quantity is >1 | The system matches charges by DOS, CPT code, and quantity. When charges are identified, the allowed, payment, and adjustment amounts are divided by the quantity and posted to the charge lines equally. Patient-responsible amounts for deductible (PR1) co-insurance (PR2) and copay (PR3) are distributed equally only for reporting and COB balancing. Adjustments are not created for patient-responsible amounts. |
| Individual charges for the same CPT code and an additional charge for another CPT code. All quantity = 1 | One line with quantity > 1 and one line with quantity =1 | Enable Post Bundled Payment to Multiple Charges | Absent | Bundled payment for all charges with the same CPT, quantity >1 and a separate payment for the charge where quantity is = 1 | The system matches charges by DOS, CPT code, and quantity. When charges are identified, the allowed, payment, and adjustment amounts are divided by the quantity and posted to the charge lines equally. Line-item posting logic is used for the single line with a different CPT code. Patient-responsible amounts for deductible (PR1) co-insurance (PR2) and copay (PR3) are distributed equally only for reporting and COB balancing. Adjustments are not created for patient-responsible amounts. |