The provider would then bill the subscriber for the balance of the claim, but not the surcharge. Additionally, if the electing payor is paying their subscriber´s surcharge portion, they must properly notify the provider, in writing, of their intent. The provider would report the revenue received from the electing payor on Line 5c (Line 6c for Ambulatory Surgery Centers) of their PGP report (see Billing Example #3). Electing payor: Submits payment on the claim amount to the provider for the payor´s share of the total due submits associated surcharges directly to the PGP on the amount they paid to the provider.Where a percentage coinsurance patient obligation exists, both the payor and the patient are responsible for paying a percentage of the claim, and a percentage of the surcharge, in accordance with the terms of the subscriber contract or plan agreement. How does the HCRA surcharge apply in coinsurance arrangements? This becomes an auditable portion of a HCRA audit. It is the provider´s obligation to affirmatively clarify what choice has been made. Please note that in the absence of the electing payor notifying the provider that they have chosen option #2 above, the provider´s "default" is always to report the fixed dollar patient payment on line 10 (Line 11 for Diagnostic & Treatment Center-Ambulatory Surgery Services ) of their PGP report and pay the surcharge out of the fixed dollar payment. D&TC-Ambulatory Surgery Services: Line 18.Comprehensive Diagnostic & Treatment Center (D&TC): Line 17.If the payor chooses this option, they must notify the billing provider in writing of such action in a timely manner.ĭesignated HCRA providers receiving notification from payors of this option will report the copayment amount received from the patient on their PGP report as follows: Submit the associated surcharge amount on the patient´s copayment directly to the PGP via the payor´s PGP report on Line 2e.Hospitals will report the copayment received from the patient on Line 10 of their PGP report for payors that choose this option. Utilize billing example #2 this method calculates the surcharge before any payments are made, then subtracts out the fixed dollar copayment which reimburses the provider for the amount they have paid to the Public Goods Pool (PGP) for surcharge obligations owed from the amount they received from the patient.How does the HCRA surcharge apply in fixed dollar copay arrangements?Īn electing payor can pay the HCRA surcharge on their insured´s copayment in one of two ways: Coinsurance, Co-payments, Deductibles and other Patient Cost Sharing Issues Question Number Interplan Telecommunications System (ITS) Questions and Answers - A Complete List Table of ContentsĬoinsurance, Co-payments, Deductibles and other Patient Cost Sharing Issues All Health Care Professionals & Patient Safety.Clinical Guidelines, Standards & Quality of Care.
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