When health insurers process medical claims, they will use what is called ANSI (American National Standards Institute) group codes, along with a reason code, to help explain how they adjudicated/processed the claim.
The four group codes you could see are CO, OA, PI, and PR. They will help tell you how the claim is processed and if there is a balance, who is responsible for it.
The definition of each is:
- CO (Contractual Obligations) is the amount between what you billed and the amount allowed by the payer when you are in-network with them. This is the amount that the provider is contractually obligated to adjust from the claim. The patient is not responsible for this amount.
- OA (Other Adjustments) is used when CO (Contractual Obligation) nor PR (Patient Responsibility apply. This can be used when the claim is paid in full and there is no contractual obligation or patient responsibility on the claim.
- PI (Payer Initiated Reductions) is used by payers when it is believed the adjustment is not the responsibility of the patient. The reason code will give you additional information about this code.
- PR (Patient Responsibility) is used to identify portions of the bill that are the responsibility of the patient. These could include deductibles, copays, coinsurance amounts along with certain denials. If the patient did not have coverage on the date of service, you will also see this code.
If your payments are coming into DrChrono via ERA (Electronic Remittance Advice/835 file), these categories will post for you as well as the appropriate action taken. Any CO amounts will adjust and amounts listed under PR will be listed as patient responsibility.
If you are posting insurance payments manually, please make sure to choose these categories carefully as they will impact how the system treats the amounts. If after posting, the amount due from the patient isn't correct, this is a good place to check to ensure it is posted with the correct group code.