Remittance Advice Tutorial

Sample Remittance Advice
Medicare Administrative Contractor (MAC) and Provider Identification Section Medicare Carrier/MAC Provider Call Center telephone number Provider's name and billing address Provider's Medicare National Provider Identifier (NPI) Number Number of pages included in Remittance Advice (RA) Remittance Advice date Check/EFT number (#) Remit Announcement Section PERF PROV - The performing provider obtained from either Item 24J (if a provider within a group) or 33 (if a sole provider) on the CMS-1500 claim form. PERF PROV - The performing provider obtained from either Item 24J (if a provider within a group) or 33 (if a sole provider) on the CMS-1500 claim form. SERV DATE - The dates of service are printed under the SERV DATE column. The date of service from and the date of service through are obtained from Item 24A on the CMS-1500 claim form. SERV DATE - The dates of service are printed under the SERV DATE column. The date of service from and the date of service through are obtained from Item 24A on the CMS-1500 claim form. POS - The place of service is obtained from Item 24B on the CMS-1500 claim form. POS - The place of service is obtained from Item 24B on the CMS-1500 claim form. NOS - The number of services is obtained from Item 24G on the CMS-1500 claim form. NOS - The number of services is obtained from Item 24G on the CMS-1500 claim form. PROC - The HCPCS/CPT procedure code is obtained from Item 24D on the CMS-1500 claim form. When Medicare changes a procedure code while processing a claim, the procedure code under which the service was paid is displayed in the PROC field, followed by modifier CC (Code Change). The procedure that had originally been submitted is entered in parentheses directly under the paid procedure code. PROC - The HCPCS/CPT procedure code is obtained from Item 24D on the CMS-1500 claim form. When Medicare changes a procedure code while processing a claim, the procedure code under which the service was paid is displayed in the PROC field, followed by modifier CC (Code Change). The procedure that had originally been submitted is entered in parentheses directly under the paid procedure code. MODS - The HCPCS/CPT modifiers are printed under the MODS column. Up to four modifiers will be printed. The modifier(s) reported in Item 24D on the CMS-1500 claim form will be displayed. MODS - The HCPCS/CPT modifiers are printed under the MODS column. Up to four modifiers will be printed. The modifier(s) reported in Item 24D on the CMS-1500 claim form will be displayed. MODS - The HCPCS/CPT modifiers are printed under the MODS column. Up to four modifiers will be printed. The modifier(s) reported in Item 24D on the CMS-1500 claim form will be displayed. BILLED - The billed amount for an individual service taken from each claim line in Item 24F on the CMS-1500 claim form is displayed in this field. BILLED - The billed amount for an individual service taken from each claim line in Item 24F on the CMS-1500 claim form is displayed in this field. ALLOWED - The allowed amount represents the Medicare reimbursement rate for the specific service billed. ALLOWED - The allowed amount represents the Medicare reimbursement rate for the specific service billed. DEDUCT - This field displays the amount of any deductible applied to the claim. The patient is responsible for this amount. If an amount is displayed in this field, this is the amount that the beneficiary (or another insurer, if applicable) is responsible for paying the provider. Note: Deductible amounts are subject to change annually. DEDUCT - This field displays the amount of any deductible applied to the claim. The patient is responsible for this amount. If an amount is displayed in this field, this is the amount that the beneficiary (or another insurer, if applicable) is responsible for paying the provider. Note: Deductible amounts are subject to change annually. COINS - The coinsurance amount represents the amount for a service for which the patient is responsible. For Medicare Part B, the coinsurance amount is generally 20% of the allowed amount. If an amount is displayed in this field, this is the amount that the beneficiary (or another insurer, if applicable) is responsible for paying the provider. Note: Coinsurance amounts are subject to change annually. COINS - The coinsurance amount represents the amount for a service for which the patient is responsible. For Medicare Part B, the coinsurance amount is generally 20% of the allowed amount. If an amount is displayed in this field, this is the amount that the beneficiary (or another insurer, if applicable) is responsible for paying the provider. Note: Coinsurance amounts are subject to change annually. GRP/RC-AMT - Reason codes (RC) and amounts of adjustments are printed under the GRP/RC-AMT column. Under the standard format, only the claim adjustment reason codes approved by the American National Standards Institute (ANSI) X12 835 Insurance Subcommittee are printed under the GRP/RC-AMT column. PROV PD - The actual amount paid to the provider is printed under the PROV PD column. This amount DOES NOT include any amounts in the PREV PD, INT or LATE FILING CHARGE fields in the Provider Adjustments (ADJ) Details Section. NAME - The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. NAME - The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. NAME - The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. NAME - The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. NAME - The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form. MID - The beneficiary Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The beneficiary Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The beneficiary Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The beneficiary Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The beneficiary Medicare ID is obtained from Item 1a on the CMS-1500 claim form. ACNT - If a provider supplies the patient account number used within their office on Item 26 on the CMS-1500 claim form, Medicare will print this number, up to 20 characters, in the ACNT field to assist provider staff with identifying their patient. A zero appears if no internal number is submitted with the claim. ACNT - If a provider supplies the patient account number used within their office on Item 26 on the CMS-1500 claim form, Medicare will print this number, up to 20 characters, in the ACNT field to assist provider staff with identifying their patient. A zero appears if no internal number is submitted with the claim. ACNT - If a provider supplies the patient account number used within their office on Item 26 on the CMS-1500 claim form, Medicare will print this number, up to 20 characters, in the ACNT field to assist provider staff with identifying their patient. A zero appears if no internal number is submitted with the claim. ICN - The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. ICN - The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. ICN - The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. ICN - The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. ICN - The 13 digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. ASG - This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form. ASG - This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form. ASG - This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form. ASG - This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form. MOA - Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. MOA - Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. MOA - Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. MOA - Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. REM - Applicable remark codes are printed in the REM field. Under the standard format, only the remark codes approved by CMS are printed in this field. There is a limit of five remark code entries for a given ICN on a standard paper remittance advice. REM - Applicable remark codes are printed in the REM field. Under the standard format, only the remark codes approved by CMS are printed in this field. There is a limit of five remark code entries for a given ICN on a standard paper remittance advice. PT RESP - Patient Responsibility (PT RESP) represents the full amount for which the beneficiary or their secondary insurer can be held liable for payment by the provider. All denials or reductions from the provider's billed amount (positive and negative RCAMT entries) with a group code of PR (patient responsibility), including the deductible and coinsurance, are totaled in the PT RESP field at the end of each claim. PT RESP - Patient Responsibility (PT RESP) represents the full amount for which the beneficiary or their secondary insurer can be held liable for payment by the provider. All denials or reductions from the provider's billed amount (positive and negative RCAMT entries) with a group code of PR (patient responsibility), including the deductible and coinsurance, are totaled in the PT RESP field at the end of each claim. PT RESP - Patient Responsibility (PT RESP) represents the full amount for which the beneficiary or their secondary insurer can be held liable for payment by the provider. All denials or reductions from the provider's billed amount (positive and negative RCAMT entries) with a group code of PR (patient responsibility), including the deductible and coinsurance, are totaled in the PT RESP field at the end of each claim. PT RESP - Patient Responsibility (PT RESP) represents the full amount for which the beneficiary or their secondary insurer can be held liable for payment by the provider. All denials or reductions from the provider's billed amount (positive and negative RCAMT entries) with a group code of PR (patient responsibility), including the deductible and coinsurance, are totaled in the PT RESP field at the end of each claim. CLAIM TOTALS: BILLED, ALLOWED, DEDUCT, COINS - The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. CLAIM TOTALS: BILLED, ALLOWED, DEDUCT, COINS - The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. CLAIM TOTALS: BILLED, ALLOWED, DEDUCT, COINS - The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. CLAIM TOTALS: BILLED, ALLOWED, DEDUCT, COINS - The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. CLAIM TOTALS: BILLED, ALLOWED, DEDUCT, COINS - The totals: # OF CLAIMS, BILLED AMT, ALLOWED AMT, DEDUCT AMT (deductible) and COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. # OF CLAIMS - The total # OF CLAIMS are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. BILLED AMT - The total BILLED AMT amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. ALLOWED AMT - The total ALLOWED AMT amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. DEDUCT AMT - The total DEDUCT AMT (deductible) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. COINS AMT - The total COINS AMT (coinsurance) amounts are calculated from each claim line. They identify the total amount of all claim totals, for each column heading respectively. PREV PD - When a claim has been adjusted, the dollar amount previously paid to the provider for services on the original claim is reflected in this field. INT - The interest field represents the amount of interest paid on the original claim. LATE FILING CHARGE - The total late filing amount reported on the remittance advice is an accumulation of the late filing amounts from each line of the claim. CLAIM INFORMATION FORWARDED TO - When claim information is forwarded to the patient's supplemental insurer, the name of that other payer or carrier to whom the data was sent is displayed. NET - This field represents the net paid amount for a given claim, including interest. NET - This field represents the net paid amount for a given claim, including interest. NET - This field represents the net paid amount for a given claim, including interest. NET - This field represents the net paid amount for a given claim, including interest. NET - This field represents the net paid amount for a given claim, including interest. TOTAL RC AMT - This field indicates the total amount of adjustments made to assigned claims due to Claim Adjustment Reason Codes (CARCs) listed on each service line. This excludes interest, late filing charges, deductibles, and amounts previously paid for rendered services. PROV PD - The total provider paid amount represents the total provider paid amount for all services on the claim. PROV ADJ AMT - When a claim has been adjusted, the dollar amount previously paid to the provider for services on the original claim is reflected in this field. CHECK AMT - The check amount is system calculated. This field will always display $0.00 on duplicate provider remittance advices (even when the original remit showed a payment amount). ASG - This field contains a value of N (no) for all non-assigned claims. MOA - MOA remark code MA28 is printed in the MOA field for every non-assigned claim in addition to any other applicable MOA codes. PT RESP - As the patient, or any secondary insurer, is liable for the entire amount of the claim when limitation of liability does not apply, not to exceed 115% of the Medicare fee schedule or the reasonable charge, the full amount of the bill up to the limiting charge cap is entered in the PT RESP field for a non-assigned claim. If limitation of liability does apply, and the beneficiary did not sign an Advanced Beneficiary Notice (ABN), the waiver to assume financial responsibility, the amount of the denied services is excluded from the total in the PT RESP field. If limitation of liability does apply and the beneficiary signed an ABN, the full amount of the bill up to the limiting charge cap, is entered in the PT RESP field for the non-assigned claim. Denial amounts subject to limitation of liability (for which the beneficiary did not sign a waiver to assume financial responsibility) and reduction amounts in excess of 115% of the Medicare fee schedule or the reasonable charge are shown with a group code of 'CO.' PT RESP = BILLED - RC-AMTs signified with group code CO. Totals Section RC-AMT - Non-assigned claims in excess of 115% of the Medicare fee schedule or reasonable charge amount will display reason code CO-45. The reduction representing the difference between the limiting charge and the allowed amount will be shown with group and reason code PR-42 for non-assigned claims. PROV PD - $0.00 is printed in the PROV PD column for non-assigned claims. PROVIDER ADJ DETAILS - Offsets to payments, are shown as an adjustment to the provider's payment at the summary level, rather than as an adjustment at an individual claim level in the remittance advice. Offsets may be taken when two or more providers are affiliated and have the same Tax Identification Number (TIN), payments may be withheld from one provider (PTAN) to collect another provider's (PTAN) overpayments. PLB REASON CODE - Description This field indicates the provider-level adjustment reason code. FCN - The Financial Control Numbers (FCNs) enable the provider to associate the offset with those claims and payments that led to the withholding. (Billing entity) This field indicates the Financial Control Number (FCN) that this adjustment relates to when the adjustment refers to a claim that appeared on a previous SPR. This usually matches the ICN field of the previous claim. If the adjustment in question does not relate to a specific claim, this field is blank. MID - The beneficiary's Medicare ID is obtained from Item 1a on the CMS-1500 claim form. AMOUNT - Amount taken back (recouped). If a negative amount is showing, amount has not been taken back yet with the PLB Reason code FB but will be. This gives suppliers the chance to pay back the debt before the money is recouped. Note: When money is taken back by TIN, if supplier cannot determine who money is taken back on, call the Provider Contact Center for your Jurisdiction. Glossary Section Glossary Section Glossary Section Glossary Section Glossary Section Glossary Section
Sample Remittance Advice Glossary
Glossary Section

 

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