Copay

A copay is the simplest patient share: a flat amount per service. HealthCare.gov defines a copayment as a fixed amount, $20 for example, that you pay for a covered health care service after you have paid your deductible, and notes that the plan’s allowed amount does not change what the patient owes: on a $100 allowed visit with a $20 copay, the patient pays $20. Plans set different copays for primary care, specialists, urgent care, emergency visits and prescriptions, and the amount is printed on the member’s card and returned in the eligibility response.

Copays matter because they are the only patient share a practice can collect with certainty at check-in. The card and the eligibility check say the amount, the front desk collects it, and when the ERA arrives the PR line with CARC 3, the copayment amount, is matched to the payment already taken. Whether the copay applies before the deductible is met, and whether it counts toward it, depends on the plan design, which is why the eligibility response has to be read rather than assumed.

The mistake is treating the copay as the whole patient balance. A visit can carry a copay and coinsurance and deductible on different lines, so a patient who paid at the desk may still owe more after adjudication, and a practice that stops at the copay leaves that money uncollected. The opposite error is collecting a copay for a service the plan exempts and then owing a refund. Read the PR codes line by line, reconcile them to the front desk payment, and bill or refund the difference.