Apex Claim Adjustments for Submitting to Secondary Insurance Providers

  Permissions: You must have Billing Permissions. 

If you are not set up to pull in ERAs from the clearinghouse you can apply an adjustment to a Client's Invoice manually from the Client's Ledger.

NOTE: Currently Adjustments do not affect the balance on the Invoice.

1. Locate Client and open Client Profile.
2. Click Client Ledger in side menu and locate appropriate Invoice.
3. Click Action and click View Details.
   
   
   
4. Click + Add Adjustment button at top.
   
   
   
5. Select the Service.
6. Select Type of Adjustment.
7. Choosing the Adjustment Type will autofill the Group and Reason code field.
   
   
   Below are Adjustment Types found in WebABA with their Group and Reason Codes and descriptions:
   

   Type	Group & Reason Code	Description
   Deductible	PR 1	Amount was not paid due to being Client responsibility: Deductible.
   Coinsurance	PR 2	Amount was not paid due to being Client responsibility: Coinsurance.
   Copayment	PR 3	Amount was not paid due to being Client responsibility: Copayment.
   Amount Exceeds Contracted Rate	CO 45	Amount was not paid as it exceeds the agreed upon insurance contracted rate.
   Regulatory Surcharges	CO 137	Amount was not paid due to regulatory surcharges, assessments, allowances or health-related taxes.
   Provider Speciality	CO 172	Amount not paid when performed/billed by a provider of this specialty.
   Sequestration	CO 253	2% payment reduction of contracted rate related to Medicare.
   Misc/Other		This can be used with other Group and Reason Codes not listed above.

    
8. Finally, enter the Adjustment Amount and Payment Date.
   

   Note: When you submit an Electronic Claim to Secondary Insurance you'll want to use the Adjustments on the Invoice so Secondary Insurance knows which portions were not paid. The Adjustment amounts identified as not paid is everything that the Primary Insurance did not cover.

   • Adjustment + Invoice Payments = Original Balance of Invoice
   • Adjustment = Unpaid Amount
   • The Adjudication (Payment) Date = The date the claim was paid by primary ~ the ERA/EOB date or date on the check (if paid by paper check).
9. Mark whether this Adjustment was paid or not.
   1. Checked - Paid by Primary Insurance.
   2. Unchecked - Not Paid by Primary Insurance.
10. Click Save.
    
    
    
11. The Adjustment now displays at the bottom of the Invoice and will be pulled in when you submit the Claim to the Secondary Insurance Provider.