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Remittance Advice Tutorial

Sample Remittance AdviceMedicare 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 (#) 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 CMS1500 claim form. NOS - The number of services is obtained from Item 24G on the CMS1500 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. This situation will occur when a procedure is down-coded. 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. This situation will occur when a procedure is down-coded. 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 or those added by Noridian for pricing reduction (i.e., 51) or as notification of a change to the submitted procedure 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 or those added by Noridian for pricing reduction (i.e., 51) or as notification of a change to the submitted procedure 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 or those added by Noridian for pricing reduction (i.e., 51) or as notification of a change to the submitted procedure 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 other 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 other 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 other 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 other insurer, if applicable) is responsible for paying the provider. NOTE: Coinsurance amounts are subject to change annually. GRP/RC-AMT - Reason codes (RC) and amount 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 Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The Medicare ID is obtained from Item 1a on the CMS-1500 claim form. MID - The 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. 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. 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. 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. 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. 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. 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. 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. 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 claims 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 claims 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 claims 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 claims 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 claims 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. ADJS - 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. This difference between the current interest on the adjustment claim and the previous interest from the original claim is displayed in this field. CMS requires Medicare to pay interest on claims submitted with complete information when not paid by the 30th day after the date of receipt. Interest is not required on claims requiring external investigation or development, claims for which no payment is due or claims which are full denials. The Treasury Department determines the rate of interest. The total interest amount reported on the remittance advice represents all claim level interest amounts. This amount can be either a positive or negative value. If the previous interest is more than the current interest, then this field will be a positive number. If the previous interest is less than the current interest, then this field will be a negative number. The signed amount (whether it is positive or negative) is based on the difference between the current interest and the previous interest. 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. This amount can be either a positive or negative value. If the previous late filing is more than the current late filing, then this field will be a negative number. If the previous late filing is less than the current late filing, then this field will be a positive number. Claims must be filed no later than the end of the calendar year following the year in which the services were provided. However, the filing limit is extended another full year if the service was provided during the last three months of the year. For Medicare assigned claims filed more than one year from the service date, payment will be reduced by 10%. This 10% reduction cannot be billed to the patient. 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. If the beneficiary has multiple crossover companies only one will print in this section. The following MOA message accompanies claims that have been forwarded to a supplemental insurer: MA18: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. Note: Although MOA message MA18 appears on claims forwarded to MEDIGAP companies, the name of a MEDIGAP insurer to whom data has been forwarded is not printed in this section. Providers can locate the MEDIGAP insurer by researching the data submitted in Items 9 through 9d on the CMS-1500 claim form. 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. # OF CLAIMS - This field represents the total number of assigned claims reported on the remittance advice. BILLED AMT - The total billed amount represents the sum of CLAIM TOTALS: BILLED amounts for each assigned claim reported on the remittance advice. ALLOWED AMT - The total allowed amount represents the sum of CLAIM TOTALS: ALLOWED amounts for each assigned claim reported on the remittance advice. DEDUCT AMT - The total deductible amount is the sum of CLAIM TOTALS: DEDUCT amounts for each assigned claim reported on the remittance advice. COINS AMT - The total coinsurance amount represents the sum of CLAIM TOTALS: COINS amounts for each assigned claim reported on the remittance advice. 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 AMT - This field displays the total payment amount for claims before any provider adjustments are applied. PROV ADJ AMT - This amount represents the sum of the PROVIDER ADJ DETAILS section on the remittance advice for the assigned claims. 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). Offsets to payments, perhaps for a prior Medicare overpayment, 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. This field indicates the provider-level adjustment reason code. The Financial Control Numbers (FCNs) enable the provider to associate the offset with those claims and payments that led to the withholding. 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. A single Medicare ID is printed if the offset is for a Medicare overpayment and a Medicare ID is associated with the offset. The Medicare ID will not be supplied if none is associated with the offset. Multiple Medicare IDs are not printed in this field, as the paper remittance advice must be consistent with the electronic remittance advice standard that only permits a single Medicare ID in this field. The amount being withheld or added in by the transaction for the FCN is always printed at the provider summary level. 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. 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. MA28:Receipt of this notice by a physician who did not accept assignment is for information only and does not make the physician a party to the determination. No additional rights to appeal this decision, above those already provided for by regulation/instruction, are conferred by receipt of this notice. 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 physician 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. Glossary Section Glossary Section Glossary Section Glossary Section Glossary Section Glossary Section

 


Sample Remittance Advice GlossaryGlossary Section

Last Updated Fri, 23 Feb 2018 12:52:05 +0000