After Medicare processes a claim, it issues a Remittance Advice (RA) in either a Standard Paper Remittance (SPR) or Electronic Remittance Advice (ERA) format. An RA provides finalized claim details and includes explanatory claim processing message codes.

Standard Paper Remittance (SPR) Field Descriptions - View SPR field headings and descriptions.

EDISS - Electronic Remittance Advice (ERA) 835 - Electronic version of SPR. Serves as a notice of payments and adjustments send to providers, billers and suppliers. Explains reimbursement decisions of payer.

Medicare uses three code sets at the claim or service line level on an RA: Claim Adjustment Group Codes, Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC). Medicare also uses Provider Level Balance (PLB) Reason Codes to explain any adjustment at the provider level.

Claim Adjustment Group Codes - Used with a CARC to assign financial responsibility for amounts not covered by Medicare for a claim or service line balance.

• CO (Contractual Obligations) - Indicates that a contractual agreement between the payer and payee, or another requirement, resulted in an adjustment. Providers are financially responsible for CO adjustment and may not bill them to the patient.
• OA (Other Adjustments) - Identifies adjustments when no other group code applies.
• PR (Patient Responsibility) - Indicates an amount that may be billed to the patient or insured. Providers typically see this code for deductible or copayment amounts.

Claim Adjustment Reason Codes (CARCs) - Medicare uses this standardized national code set on remittance advice to explain financial adjustments, such as denials, payment reductions or payment increases. Medicare applies CARCs at the claim or service line level to communicate why payment differs from the billed amount. X12 updates the official CARC list three times each year (on or around March 1, July 1, and November 1) and publishes it on their website: X12 - Claim Adjustment Reason Code (CARCs)

Remittance Advice Remark Codes (RARCs) - Medicare uses this standardized national code set at the claim or service line level to provide additional information about an adjustment already identified by a CARC. X12 updates the official RARC list is updated three times a year (on or around March 1, July 1, and November 1) and publishes it on their website: X12 - Remittance Advice Remark Codes (RARCs)

RARC Alerts - Provide general adjudication information and do not offer additional explanation for a specific adjustment. For example: MA01: Alert: If you do not agree with what we approved for these services, you may appeal our decision.

Denial Code Resolution - View common claim submission error codes, descriptions of issues, and potential solutions.

Provider Level Balance (PLB) or Provider Level Adjustment Reason Codes - Explain adjustments that usually do not relate to any specific claim or service line in the remittance advice. Examples include:

1. Medicare increases payment to include interest owed because it did not pay a clean claim timely.
2. Medicare deducts payment to recover a prior overpayment.
3. Medicare increases payment under a provider incentive program.

Qualified Medicare Beneficiary (QMB) Program - View QMB program information and related remit advice remark codes

Resources

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 22, Section 60
• CMS Health Care Payment Remittance Advice