Stream: CARIN BB ExplanationOfBenefit
Topic: Item.adjudication and header adjudication
Chetana Nayyar (Apr 27 2021 at 09:17):
For the 4 profiles under Carin BB only the institutional profiles(Inpatient and Outpatient) mention explicitly that only one of the adjudication needs to be provided
.adjudication.amount (populate only if item.adjudication is not available): Eligible amount = submitted amount - the noncovered amount - discount. The subscriber pays the member liability = deductible + coinsurance + copay + noncovered. (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
Any reason why this does not apply to Pharmacy and Professional profiles?
Last updated: Apr 12 2022 at 19:14 UTC
