MSP Calculation Examples on EOBs

View examples of different primary Explanation of Benefits (EOBs) and how to calculate the specific fields that determine the allowed amount, patient responsibility, and Obligated to Accept Payment in Full (OTAF) amount for Medicare Secondary Payer (MSP) claims.

Example One

This is a primary insurance explanation of benefits (EOB). Field 1 BILLED AMT ($103.67) - Field 2 TOTAL CARC-AMT ($72.01) = Field 3 ALLOWED AMT ($31.66), Field 3 ALLOWED AMT ($31.66) - Field 4 PROV PD AMT ($31.66) = Field 6 PT RESP ($0.00), Field 5 Explanation of Benefits (EOB) also contains CARC CO-16: Entered on the Direct Data Entry (DDE) claim page 41 in the CARC amount, Field 1 BILLED AMT ($103.67) - Field 4 PROV PD AMT ($31.66) = Field 2 TOTAL CARC-AMT ($72.01).

  • Field 1 BILLED AMT ($103.67) - Field 2 TOTAL CARC-AMT ($72.01) = Field 3 ALLOWED AMT ($31.66)
  • Field 3 ALLOWED AMT ($31.66) - Field 4 PROV PD AMT ($31.66) = Field 6 PT RESP ($0.00)
  • Field 5 Explanation of Benefits (EOB) also contains CARC CO-16: Entered on the Direct Data Entry (DDE) claim page 41 in the CARC amount
    • Field 1 BILLED AMT ($103.67) - Field 4 PROV PD AMT ($31.66) = Field 2 TOTAL CARC-AMT ($72.01)

Example Two

This is a primary insurance explanation of benefits (EOB). Field 1 Charge Amount ($90.00) - Field 2 Negotiated Adjustment ($1.80) = Primary Allowed Amount ($88.20), Primary Allowed Amount ($88.20) is the Obligated to Accept Payment in Full (OTAF) amount for the value code 44, Primary allowed amount ($88.20) - Field 4 ($68.20) = Field 3 Co-payment Amount, this EOB does not contain any Claim Adjustment Reason Codes (CARCs).

*Ineligible amount is the same as Negotiated Adjustment

  • Field 1 Charge Amount ($90.00) - Field 2 Negotiated Adjustment ($1.80) = Primary Allowed Amount ($88.20)
  • Primary Allowed Amount ($88.20) is the Obligated to Accept Payment in Full (OTAF) amount for the value code 44
  • Primary allowed amount ($88.20) - Field 4 ($68.20) = Field 3 Co-payment Amount
  • This EOB does not contain any Claim Adjustment Reason Codes (CARCs)

Example Three

This is a primary insurance explanation of benefits (EOB). Field 1 Amount Billed ($86367.36) - Field 2 Premera Network Discount ($64508.76) = Primary Allowed Amount ($21858.60), Field 3 Amount Paid By Your Health Plan ($21858.60) - Primary Allowed Amount ($21858.60) = Field 4 Your Total Responsibility ($0.00), this EOB does not contain any Claim Adjustment Reason Codes (CARCs).

  • Field 1 Amount Billed ($86367.36) - Field 2 Premera Network Discount ($64508.76) = Primary Allowed Amount ($21858.60)
  • Field 3 Amount Paid By Your Health Plan ($21858.60) - Primary Allowed Amount ($21858.60) = Field 4 Your Total Responsibility ($0.00)
  • This EOB does not contain any Claim Adjustment Reason Codes (CARCs)

 

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