How to Read an EOB with a Negative Dollar Amount
Release 1-2007
Effective March 26, 2007
This scenario occurs when a provider does not have the "Lesser of Billed (LOB)" language built into their contract.
Meaning if the claim billed amount is less than the provider's contracted rate, Coventry is obligated to pay the contracted rate. In order for such a claim to balance, the dollar amount shown in the "Ineligible Amt." column will be a
negative value and balance to the dollar amount shown in the "Approved Amt." column.
The below claim is BEFORE Release 1. The Ineligible Amount shows $0.00 because the
disposition code attached to the negative dollars did not appear on the EOB.
NOTES:
EOBs must
balance two ways
Billed - Ineligible - Other
= Approved
(1-2-6=3)
AND
Approved - Mbr Resp. =
Plan Paid
(3- 4-5=7)
The below claim is AFTER Release 1. The Ineligible Amount shows negative dollars with
the corresponding disposition code on the EOB.
Helpful Hints:
* Dollars
located in the
Other column (6) are NOT
included in the Approved
Amt. (3) dollars.
1
2
3
4
5
6
7
* When totaling dollars in the
row (left to right) you must
ADD in the
negative dollar value to get it
to balance.
* When balancing the dollars
in the TOTALS row (left to
right) you must SUBTRACT
the Ineligible Amt dollar value
to get it to balance.
* When totaling the
dollars in the column (up and
down) you must subtract the
negative dollar value to get it
to balance.
The below claim is BEFORE Release 1. The Ineligible Amount shows $0.00 because the
disposition code attached to the negative dollars did not appear on the RA.
The below claim is AFTER Release 1. The Ineligible Amount shows negative dollars with the corresponding disposition code on the RA.
1
2
3
4
5
How to Balance the RA
Total Charges - Ineligible Amt - Member Responsibility = Plan Paid.
(1-3-4=5)
Helpful Hints
•
When totaling dollars in the row (left to right) you must ADD in the negative dollar value to get it to
balance.
•
When balancing the Totals row (left to right) you must subtract the Ineligible Amount dollar value to
get the line to balance.
•
When totaling the dollars in the column (up and down) you must subtract the negative dollar value to
get it to balance.