Remittance Advice Field Descriptions - JA DME
Remittance Advice Field Descriptions
Medicare Administrative Contractor (MAC) and Provider Identification Section
The first page of a paper remittance advice is identified with a statement, "MEDICARE REMITTANCE ADVICE" and contains complete information on the carrier and billing information for the provider, as follows:
- Medicare Carrier/MAC identification and complete address
- Medicare Carrier/MAC Provider Call Center telephone number
- Provider's name and billing address
- Provider's Medicare National Provider Identifier (NPI) #
- Number of pages included in Remittance Advice (RA)
- Remittance Advice date
- Check/EFT number (#)
Note: If a remittance advice contains multiple pages, the subsequent pages will contain abbreviated carrier and provider information, which excludes the mailing and telephone information.
Remit Announcement Section
Medicare related messages, reminders and other urgent and/or important information are displayed at the beginning of the paper remittance advice in an asterisk (*) segmented box.
Standard Paper Remit (SPR) Field Headings and Descriptions
Abbreviations must be used in the claim and detail information to maximize the amount of the data that can reasonably and legibly be printed across the page. In most cases, the abbreviations should be self-explanatory. Each field found in this section is discussed as follows:
Body of Remittance Advice
|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.
|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.
|The place of service is obtained from Item 24B on the CMS-1500 claim form.
|The number of services is obtained from Item 24G on the CMS-1500 claim form.
|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.
|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.
|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.
|The allowed amount represents the Medicare reimbursement rate for the specific service billed.
|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.
|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.
|Group (GRP) Values:
|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.
|The name of the beneficiary is obtained from Item 2 on the CMS-1500 claim form.
|The beneficiary's Medicare ID is obtained from Item 1a on the CMS-1500 claim form.
|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.
|The 13-digit Internal Control Number (ICN) identifies the processed claim and is needed when contacting Medicare about the processed claim. The first two digits of the Internal Control Number that appear on your payment listing will show the type of claim or claim adjustment. The next two digits of the ICN will show the two-digit year the claim was received, or the adjustment was initiated. The remaining digits are a sequential number, assigned to each claim on the Julian date, in numeric order.
|This field displays whether the provider accepted assignment, Y (yes) or N (no) in Item 27 on the CMS-1500 claim form.
|Medicare Outpatient Adjudication (MOA) remark codes are used to convey appeal information and other claim-specific information that does not involve a financial adjustment. A maximum of five Medicare outpatient adjudication (MOA) remarks code(s) per ICN are printed in the MOA field. (Codes listed on each claim line in the MOA section will be defined in the Glossary at the end of the RA.) Under the standard format, only the MOA codes approved by CMS are used. The complete list of remark codes is available on the X12 Remittance Advice Remark Codes webpage. Select "Remittance Advice Remark Codes" from the "HIPAA-Related Code Lists" page.
|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. The list of remark codes is available on the X12 Remittance Advice Remark Codes webpage. Select "Remittance Advice Remark Codes" from the "HIPAA-Related Code Lists" page.
|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. The patient responsibility is obtained through the following calculation:
PT RESP = DEDUCT + COINS + RC-AMTs signified by group code PR
|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.
|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.
|This field represents the net paid amount for a given claim, including interest.
Totals Summary Section
To help providers balance their billed amounts against the Medicare payments and adjustments, paid and adjusted amounts are totaled at the end of the assigned claims listing.
|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.
|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.
|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.
|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).
Provider Adjustment (ADJ) Details Section
Offsets (recoupments) 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 on the remittance advice in the provider adjustment (ADJ) Details Section.
Offsets may be taken when two or more providers with multiple National Provider Identifiers (NPI)s 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.
Note: When money is taken back by TIN with multiple NPIs, if supplier cannot determine who money is taken back (recouped) on, call the Provider Contact Center for your jurisdiction to obtain that information (Suppliers may be required to leave a message and receive a call back).
PLB REASON CODE - This field indicates the provider-level adjustment reason code.
Provider Adjustment (ADJ) Details Section
PLB Reason Codes
|Net of all late file charges (positive and negative) of all the impacted claims on the remittance advice. Used to identify Late Claim Filing Penalty.
|Used to reflect accelerated payment amounts or withholdings. A positive value represents a withholding. A negative value represents a payment.
|Refund - Used to reflect accelerated payment amounts or withholdings. A positive value represents a withholding. A negative value represents a payment.
|Adjustment - Used to provide supporting identification. Code "RI" is used on a Professional RA for a Reissued Check Amount (e.g., CS/RI).
|When an account receivable is created, it is tied to a CCN. The FCN field will reflect the CCN that corresponds to the account payable record or overpayment.
Forward Balance: This value can represent one of three things:
|Internal Revenue Service Withholding - Used for Internal Revenue Service withholdings.
|Non-reimbursable - Used to offset claim or service level data that reflects what could be paid if not for demonstration programs or other limitation that prevents issuance of payment. For example, this is used to zero balance provider payment for Centers of Excellence and Medicare Advantage RAs.
|Interest owed - If the net interest is added to the "TOTAL PROV PD" amount, then the offset detail will be a negative number. If it is subtracted from the "TOTAL PROV PD" amount, then the offset detail will be a positive number.
|Levy - Used for IRS levy
|Student Loan Repayment - Used to represent a student loan repayment.
|Offset as a result of a previous overpayment (A/R accounts receivable). Used to recover previous overpayment. A reference number (the original ICN and Medicare ID) is applied for tracking purposes.
Important Note: In HIGLAS when two or more providers are affiliated with multiple NPIs and have the same Tax Identification Number (TIN), payments may be withheld from one provider (PTAN) to collect another provider's (PTAN) overpayments.
When money is taken back by TIN, if supplier cannot determine the PTAN who money is being taken back (recouped) on, call the Provider Contact Center for your jurisdiction to obtain that information (Suppliers may be required to leave a message and receive a call back).
Example: Supplier 123 PTAN in California receives remittance advice. An offset is taken back (recouped) from supplier 345 PTAN in Florida. Both suppliers under same TIN but supplier 123 is unable to locate account in their accounts receivable to balance account. Contact the Provider Contact Center for your jurisdiction to obtain this information.
|Levy - Used for Federal Payment Levy Program
|If the financial transaction is tied to an ICN, the ICN will be plugged in the FCN field. If the financial transaction is NOT tied to an ICN, the CCN will be plugged in the FCN field.
|Will always be blank as Medicare ID information is not applicable for these types.
|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.
The FCN is the corresponding CCN with a 1 in front.
|Claim Control Number. This is the number that account was taken back from (money recouped)
|Patient account number billed on claim
|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
The remark and/or reason code that appears in the Claim Detail Information Section of the remittance advice has the associated message description printed in the Glossary Section to facilitate interpretation.
Codes and related message descriptions are printed in the following order:
- Group codes
- Reason codes
- Line level remark codes
- Claim level remark codes/MOA
- Claim and detail level remark codes
- Adjustment codes
|Each group code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same group code appears multiple times, it will be printed only once.
|GROUP CODE MESSAGE
|The message for each group code is defined by CMS and displays on the remittance advice as applicable.
|Each reason code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same reason code appears multiple times, it will be printed only once.
|REASON CODE MESSAGE
|The message for the reason code is listed under this section.
|Each remark code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same remark code appears multiple times, it will be printed only once.
|REMARK CODE MESSAGE
|The message for the remark code is listed under this section.
|Each MOA code appearing in the Claim Detail Information Section of the remittance advice is listed under this section. If the same MOA code appears multiple times, it will be printed only once.
|MOA CODE MESSAGE
|The message for the MOA code is listed under this section.
|Each adjustment code appearing in the Provider Adjustment (ADJ) Details Section of the remittance advice is listed under this section. If the same offset code appears multiple times, it will be printed only once.
|ADJUSTMENT CODE MESSAGE
|The message for each adjustment code is defined by CMS and displays on the remittance advice when applicable.
Summary of Non-Assigned Claims Section
If a remittance advice contains both assigned and non-assigned claims, information on any non-assigned claims will be listed separately after the assigned claims to avoid any inadvertent use of non-assigned claims information, for which Medicare payment is not issued to a provider, to balance accounts.
Claim listings included in the remittance advice are printed in the following order:
- In the assigned claims section, pay claims appear first followed by non-pay claims. Since all non-assigned claims to providers are non-pay claims, they will appear in alphabetical order by the beneficiary's last name.
- Multiple claims having the same beneficiary's name will appear in ICN order.
The standard remittance advice format and messages provide all data in the beneficiary Medicare Summary Notice (MSN), except for any interest paid to the beneficiary. Fields contained in the summary of non-assigned claims sections are identical to the fields contained in the assigned claim and detail information section. Therefore, only information, which pertains to non-assigned claims, is discussed below:
|This field contains a value of N (no) for all non-assigned claims.
|MOA remark code MA28 is printed in the MOA field for every non-assigned claim in addition to any other applicable MOA codes.
|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.
|$0.00 is printed in the PROV PD column for non-assigned claims.
|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.
|Interest payments to beneficiaries are not shown on a provider's remittance advice, just as interest to a provider is not shown on a beneficiary's Medicare Summary Notice. Therefore, the INT field under the SUMMARY OF NONASSIGNED CLAIMS section in the standard provider remittance advice will always contain 0.00 for non-assigned claims, regardless of whether or not the payment accrued interest. Beyond that, all (non-bulletin) payment information on an MSN agrees with that on the remittance advice for the same claim.
|AMOUNT PAID TO BENEFICIARY
|The amount paid to the beneficiary will display as OA-100 in the GRP/RC-AMT field. For adjustments, this amount will include the amount paid to the beneficiary on the base and adjusted claim.
|NON-ASSIGNED CLAIM/NON-PARTICIPATING PROVIDER BILLING FOR MORE THAN 115% OF LIMITING CHARGE
|The amounts a provider may and may not bill a beneficiary must be expressed on a remittance advice through use of group codes and 835 adjustment reason codes. Reason code 45, charges exceed your contracted/legislated fee arrangement, is used when a non-participating provider has billed for more than 115% of the limiting charge. The provider must refund any amount already collected from the beneficiary or a representative in excess of the amount shown in the total Patient Responsibility field.