Stream: CARIN BB ExplanationOfBenefit
Topic: header adjudication and total adjudication
Chetana Nayyar (Apr 27 2021 at 09:23):
Kindly explain how different are these header adjudication and total adjudication since the slice adjudicationcategory has the same valueset
.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)
.total.amount: 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)
Screenshot-2021-04-27-at-2.51.09-PM.png
Last updated: Apr 12 2022 at 19:14 UTC
