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Clarification: Collecting member cost-sharing

July 27, 2018

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
3/9/201899203$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
3/9/201899203$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
13/9/201899212$154.00$58.31$58.31$0.00
23/9/201820605$121.00$54.73$21.69$33.04
33/9/2018J3301$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.


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