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Aspirion EOB and Reason Code Terms

1. Contractual amount (obligation)

2. Claim adjustment reason code

3. remark code

4. Denial code

8. patient responsibility

9. secondary (insurance)

10. drg

5. deductible

6. coinsurance

7. Co-payment

11. sequestration

The difference between what a healthcare provider bills for the service rendered versus what will be contractually paid (or should be paid) based on the terms of its contracts with third-party insurers and/or government programs.

Appears on an explanation of benefits (EOB) to communicate why a claim has been adjusted. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Codes assigned by health care insurance companies to faulty insurance claims. They include reason and remark codes that outline reasons for not covering patients’ treatment costs. You can refer to these codes to resolve denials and resubmit claims.

Specified amount or capped limit the insured person must pay first before the insurance will begin paying medical costs.

The portion of a medical bill that the patient is required to pay rather than their insurance provider.

Plan in addition to primary health insurance. Secondary insurance can help you improve your coverage by giving you access to additional medical providers, such as out-of-network doctors. It can also provide benefits for uncovered health services, such as vision or dental. For example, a person that is retired is covered by their spouse's insurance (primary) and the person is also covered by Medicare (secondary) which would pay all or some of the balance not paid by the primary insurance carrier.

A diagnostic related group which groups diagnosis and procedure codes that determines how much the insurance carrier will pay.

Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

A percentage of a medical charge the insured person pays, with the rest paid by your health insurance plan, which typically applies after your deductible has been met.

A fixed out-of-pocket amount paid by an insured person for covered services.

Usually seen on Medicare EOBs, is a process of automatic, largely across-the-board spending reductions under which budgetary resources are permanently canceled to enforce certain budget policy goals.