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After the insurance carrier makes a decision on a claim and the practice receives and posts the payment, the patient's balance must be calculated. The claim case studies in this section provide practice in calculating balances by using the latest payment information obtained from RAs for each patient in Chapter 15, Claim Cases 15.1 through 15.20. Use this information to calculate each patient's balance in the following case studies.

Case Study 16.9
Patient: Joseph Zylerberg
The following information is taken from two RAs. The first RA is from Medicare Nationwide, the primary payer. Note that the patient has met the deductible for the primary payer. The second RA is from Medicaid, the secondary carrier. The patient's Medicaid copay for the secondary plan has not yet been paid.

PRIMARY CARRIER
\begin{tabular}{lllllll}
POS & PROC & BILLED & ALLOWED & DEDUCT & COINS/COPAY & PROV PD \\
11 & 99204 & 150.00 & 103.00 & 0.00 & 20.60 & 82.40 \\
11 & 93000 & 70.00 & 29.00 & 0.00 & 5.80 & 23.20
\end{tabular}

SECONDARY CARRIER
\begin{tabular}{lllllll}
POS & PROC & BILLED & ALLOWED & DEDUCT & COINS/COPAY & PROV PD \\
11 & 99204 & 150.00 & 103.00 & 0.00 & 15.00 & 5.60 \\
11 & 93000 & 70.00 & 29.00 & 0.00 & 0.00 & 5.80
\end{tabular}



Answer :

GinnyAnswer
To determine the patient's balance after both the primary and secondary insurance carriers have made their respective payments, we follow these steps:

### Step 1: Gather Information from the Primary Carrier
- Procedure 99204: The primary carrier has paid [tex]$82.40. - Procedure 93000: The primary carrier has paid $[/tex]23.20.

### Step 2: Gather Information from the Secondary Carrier
- Procedure 99204:
- Coinsurance/Copay: [tex]$15.00 - Provider Payment: $[/tex]5.60
- Procedure 93000:
- Coinsurance/Copay: [tex]$0.00 - Provider Payment: $[/tex]5.80

### Step 3: Calculate the Remaining Balance for Each Procedure
#### Procedure 99204
1. Primary Carrier Provider Payment: [tex]$82.40 2. Secondary Carrier Coinsurance/Copay: $[/tex]15.00
3. Secondary Carrier Provider Payment: [tex]$5.60 The remaining balance for Procedure 99204 is calculated as: \[ \text{Primary Carrier Provider Payment} - (\text{Secondary Carrier Coinsurance/Copay} + \text{Secondary Carrier Provider Payment}) \] \[ 82.40 - (15.00 + 5.60) = 82.40 - 20.60 = 61.80 \] #### Procedure 93000 1. Primary Carrier Provider Payment: $[/tex]23.20
2. Secondary Carrier Provider Payment: [tex]$5.80 The remaining balance for Procedure 93000 is calculated as: \[ \text{Primary Carrier Provider Payment} - \text{Secondary Carrier Provider Payment} \] \[ 23.20 - 5.80 = 17.40 \] ### Step 4: Calculate the Total Remaining Balance To find the total remaining balance, we sum the remaining balances for both procedures: \[ \text{Total Remaining Balance} = \text{Remaining Balance for Procedure 99204} + \text{Remaining Balance for Procedure 93000} \] \[ 61.80 + 17.40 = 79.20 \] ### Conclusion The patient's remaining balance after the primary and secondary carriers have made their payments is $[/tex]79.20. This is the amount that the patient or another responsible party needs to pay to settle the balance for the services rendered.

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