This page will explain how TRAKnet applies adjustment to a downloaded remittance, and how to change how adjustment codes are applied on the insurance level.
How Adjustments are Applied
Commercial and Other Non-Medicare Insurances
For Commercial Insurances, and other insurances that are not Medicare, TRAKnet takes two types of adjustments into consideration when applying adjustments to a downloaded remittance:
- A Standard Adjustment, which is determined by the difference between the billed amount and the allowed amount on a charge
- An Additional Adjustment
The Standard Adjustment will typically reflect the adjustment for contractual obligations to the insurance. Additional Adjustments are represented on a remittance as an adjustment code other than the contractually provided amount adjustment code. For example, these may reflect incentive program bonuses or penalties, or non-payments of reporting codes.
Medicare
Any insurance that is set with an 'MB' insurance type code to designate it as a Medicare type B insurance will not calculate the Standard Adjustment mentioned above. Instead, the adjustments will be calculated by the sum of all of the adjustment codes.
Adjustment Code Settings
In the event that the adjustments on a downloaded remittance appear to be incorrect, the issue may be that the insurance has accounted for an Additional Adjustment in the allowed amount on a charge, but the Additional Adjustment is still being separately applied. For example, a MIPS reporting code that was billed for $0.01 is given an allowed amount of $0.00, which marks the adjustment as $0.01. Then, the Additional Adjustment of $0.01 is applied, resulting in a total adjustment of $0.02, and a remaining balance of ($0.01).
To account for when insurances factor in their Additional Adjustments into the allowed amount on a charge, the ability to decide which adjustment codes on a downloaded remittance may apply their adjustment can be set at the insurance level. To edit this list of adjustment codes, go to Properties > Insurance, and search for whichever insurance is having issues with their adjustments. Then, click on the Adjustment Codes tab.
Any adjustment code reflected in this list is allowed to apply its adjustment amount to the remittance. To add a code to this list, click the Add button and select the applicable Group Code and Reason Code.
If an Additional Adjustment is adjusting a charge to a negative balance or is otherwise adjusting too much, the adjustment code should be removed from this list. To remove a code, select the code and click the Remove button.
Example
The practice bills for code G4827 on their invoice for $0.01. G4827 is a reporting code for the Quality portion of MIPS, and will be adjusted to $0.00 by Medicare on the returned remittance. At one point, Medicare might not have given an allowed amount on that charge, which meant that the Additional Adjustment CO-246 (This non-payable code is required for reporting only) adjustment code had to apply a $0.01 adjustment to balance the charge at $0.00.
However, in this example, Medicare is now giving an allowed amount of $0.00, which calculates a Standard Adjustment of $0.01, but the Additional Adjustment of $0.01 is still being applied, for a total adjustment of $0.02, which takes the balance on the G4827 charge to ($0.01).
To correct this, the CO-246 adjustment code must be removed from the Adjustment Codes list at the insurance level. The remittance must then be deleted from TRAKnet and re-downloaded from Trizetto, as the Adjustment Code Settings will only apply to remittances when they are being downloaded, and will not apply to previously downloaded remittances.
